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Kanemaru K, Yoshioka H, Hashimoto K, Senbokuya N, Arai H, Fujimura M, Suzuki K, Matsuda K, Sakai N, Nishikawa R, Murayama Y, Takahashi JC, Inoue T, Yoshimura S, Tominaga T, Kinouchi H. Treatment of Unruptured Large and Giant Paraclinoid Aneurysms in Japan at the Time of Flow Diverter Introduction: A Nationwide, Multicenter Survey by the Japanese Society on Surgery for Cerebral Stroke. World Neurosurg 2025; 195:123571. [PMID: 39681259 DOI: 10.1016/j.wneu.2024.123571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2024] [Revised: 12/07/2024] [Accepted: 12/08/2024] [Indexed: 12/18/2024]
Abstract
OBJECTIVE Large or giant paraclinoid aneurysms have been treated with various strategies, including clipping, coiling, and parent artery occlusion (PAO). In addition, flow diverters (FDs) have been introduced for the management of these aneurysms. The aim of this study was to examine the management of unruptured large/giant paraclinoid aneurysms in Japan when FDs were being introduced by a nationwide survey. METHODS A total of 576 unruptured large/giant paraclinoid aneurysms treated in Japan between January 2012 and December 2016 were retrospectively studied. RESULTS Half of the large paraclinoid aneurysms were treated by coiling (50.3%), whereas giant aneurysms were occluded mainly by PAO (51.4%). A high nearly complete occlusion rate was achieved with clipping (94.1%), coiling (85.9%), PAO (82.4%), and FDs (77.6%). Coiling had higher risks of recurrence (28.3%) and retreatment (20.3%). Major procedure-related complications were observed in 9.7%. Ischemic complications were common in PAO (9.5%), with cranial nerve symptoms common in clipping (10.9%). All treatment modalities achieved good clinical outcomes (93.5%-96.6%). Although not significant, pre-existing visual disturbance improved most frequently by clipping (53.7%), but also worsened most frequently by clipping (24.4%). Consequently, FD achieved a high occlusion rate with minimal complication and retreatment rates. CONCLUSIONS All treatment modalities offer high rates of complete occlusion and good clinical outcomes. Coiling has the disadvantage of high rates of recurrence and retreatment. Clipping and PAO have the disadvantage of a high rate of major procedure-related complications; however, PAO can provide comparable treatment outcomes even in cases with refractory giant aneurysms. FDs are the optimal choice for the management for large/giant paraclinoid aneurysms due to its safety and efficacy.
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Affiliation(s)
- Kazuya Kanemaru
- Department of Neurosurgery, Interdisciplinary Graduate School of Medicine and Engineering, University of Yamanashi, Chuo, Japan
| | - Hideyuki Yoshioka
- Department of Neurosurgery, Interdisciplinary Graduate School of Medicine and Engineering, University of Yamanashi, Chuo, Japan
| | - Koji Hashimoto
- Department of Neurosurgery, Interdisciplinary Graduate School of Medicine and Engineering, University of Yamanashi, Chuo, Japan
| | - Nobuo Senbokuya
- Department of Neurosurgery, Interdisciplinary Graduate School of Medicine and Engineering, University of Yamanashi, Chuo, Japan
| | - Hajime Arai
- Department of Neurosurgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Miki Fujimura
- Department of Neurosurgery, Kohnan Hospital, Sendai, Japan
| | - Kensuke Suzuki
- Department of Neurosurgery, Dokkyo Medical University Saitama Medical Center, Koshigaya, Japan
| | - Ko Matsuda
- Department of Neurosurgery, Tominaga Hospital, Osaka, Japan
| | - Nobuyuki Sakai
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Ryo Nishikawa
- Department of Neurosurgery, Saitama Medical University International Medical Center, Hidaka, Japan
| | - Yuichi Murayama
- Department of Neurosurgery, Jikei University School of Medicine, Tokyo, Japan
| | - Jun C Takahashi
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Tooru Inoue
- Department of Neurosurgery, Fukuoka University, Faculty of Medicine, Fukuoka, Japan
| | - Shinichi Yoshimura
- Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Japan
| | - Teiji Tominaga
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Hiroyuki Kinouchi
- Department of Neurosurgery, Interdisciplinary Graduate School of Medicine and Engineering, University of Yamanashi, Chuo, Japan.
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Osada Y, Sakata H, Ezura M, Sato K, Sasaki K, Omodaka S, Kanoke A, Uchida H, Endo H. Intraoperative aneurysm flow analysis predicts intracranial large and giant aneurysm occlusion after flow diversion. Clin Neurol Neurosurg 2025; 250:108782. [PMID: 39978033 DOI: 10.1016/j.clineuro.2025.108782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2024] [Revised: 02/09/2025] [Accepted: 02/09/2025] [Indexed: 02/22/2025]
Abstract
OBJECTIVES Incompletely occluded flow-diverter (FD)-treated aneurysms are at risk of rupture and thromboembolic complications; however, intraoperative prediction of FD treatment outcomes has not yet been established. In this study, we investigated the association between intraoperative aneurysm flow analysis, using optical flow imaging, and FD treatment outcomes. MATERIALS AND METHODS This retrospective study included patients with large unruptured internal carotid artery aneurysms (≥ 10 mm) who underwent FD treatment. During the procedure, a flow analysis method using optical flow digital subtraction angiography (DSA) was used to measure the flow within the aneurysm sac by calculating the mean aneurysm flow amplitude (MAFA) before and after stent deployment. Occlusion was assessed using the O'Kelly-Marotta (OKM) grading scale on DSA 12 months after FD. The patients were divided into a nearly complete occlusion group (OKM grades C and D) and an incomplete occlusion group (OKM grades A and B). RESULTS Eleven patients with 11 aneurysms (mean age, 67.5 [standard deviation, 8.3] years; 10 women, 88.9 %) were treated with FD. Nearly complete occlusion was observed in 6/11 (54.5 %) patients at 12-month follow-up imaging. The nearly complete occlusion group had significantly lower pre-MAFA and post-MAFA values than the incomplete occlusion group (P = 0.023 and P = 0.008, respectively). There was no difference in the MAFA ratio between the two groups (P = 0.315) CONCLUSIONS: Aneurysm flow analysis before and after FD deployment is a simple and beneficial approach to predict treatment outcomes, which would indicate the need for intraoperative strategy changes, such as adding FD layers or intrasaccular coils.
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Affiliation(s)
- Yoshinari Osada
- Department of Neurosurgery, National Hospital Organization Sendai Medical Center, Sendai, Miyagi, Japan.
| | - Hiroyuki Sakata
- Department of Neuroendovascular Therapy, Kohnan Hospital, Sendai, Miyagi, Japan; Department of Neurosurgery, Kohnan Hospital, Sendai, Miyagi, Japan.
| | - Masayuki Ezura
- Department of Neurosurgery, National Hospital Organization Sendai Medical Center, Sendai, Miyagi, Japan.
| | - Kenichi Sato
- Department of Neurosurgery, National Hospital Organization Sendai Medical Center, Sendai, Miyagi, Japan.
| | - Keisuke Sasaki
- Department of Neurosurgery, National Hospital Organization Sendai Medical Center, Sendai, Miyagi, Japan.
| | - Shunsuke Omodaka
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan.
| | - Atsushi Kanoke
- Department of Neurosurgery, Kohnan Hospital, Sendai, Miyagi, Japan.
| | - Hiroki Uchida
- Department of Neurosurgery, Kohnan Hospital, Sendai, Miyagi, Japan.
| | - Hidenori Endo
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan.
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Jee TK, Yeon JY, Kim KH, Kim JS, Jeon P. Flow Diversion for Cerebral Aneurysms: A Decade-Long Experience with Improved Outcomes and Predictors of Success. Brain Sci 2024; 14:847. [PMID: 39199538 PMCID: PMC11353241 DOI: 10.3390/brainsci14080847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2024] [Revised: 08/15/2024] [Accepted: 08/19/2024] [Indexed: 09/01/2024] Open
Abstract
BACKGROUND Flow diversion has significantly improved the management of cerebral aneurysms. Technological advancements and increased clinical experience over the past decade have led to better outcomes and fewer complications. This study provides updated results and examines the factors that influence the success of flow diversion. METHODS We reviewed records of 115 patients with 121 intracranial aneurysms treated from July 2014 to August 2023. All patients had unruptured aneurysms in the anterior and posterior circulation. RESULTS Complete aneurysm occlusion was achieved in 72.7% of cases, with a complication rate of 9.1%. Significant predictors of complete occlusion included aneurysm diameter (OR = 0.89, 95% CI 0.82-0.97, p = 0.009) and the presence of incorporated branches (OR = 0.22, 95% CI 0.08-0.59, p = 0.003). Cox analysis identified neck diameter (HR = 0.92, 95% CI 0.87-0.98, p = 0.009) and incorporated branch (HR = 0.40, 95% CI 0.24-0.69, p = 0.001) as significant for occlusion. Multivariable analysis identified aneurysm diameter (OR = 1.21, 95% CI 1.09-1.37, p = 0.001) as significant for safety outcomes. Improved outcomes were observed in recent treatments, with higher occlusion rates (79.7% vs. 61.7%, p = 0.050) and lower complication rates (4.1% vs. 14.9%, p = 0.011). CONCLUSIONS Enhanced technical proficiency, better devices, and refined patient selection have significantly improved the efficacy and safety of flow diversion for cerebral aneurysms. Identifying significant predictors for treatment success and safety outcomes can inform clinical practice, aiding in patient selection.
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Affiliation(s)
- Tae Keun Jee
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea; (T.K.J.); (J.Y.Y.)
| | - Je Young Yeon
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea; (T.K.J.); (J.Y.Y.)
| | - Keon Ha Kim
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea
| | - Jong-Soo Kim
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea; (T.K.J.); (J.Y.Y.)
| | - Pyoung Jeon
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea
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Wang MX, Nie QB. Giant cavernous aneurysms occluded by aneurysmal thrombosis, calcification, parent artery occlusion: A case report and review of literature. World J Clin Cases 2024; 12:2822-2830. [PMID: 38899288 PMCID: PMC11185339 DOI: 10.12998/wjcc.v12.i16.2822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 01/26/2024] [Accepted: 03/13/2024] [Indexed: 05/29/2024] Open
Abstract
BACKGROUND Patients with giant intracranial aneurysms (GIAs) are at a high risk of rupture, morbidity, and mortality even after surgical or endovascular treatment. We described a case of a spontaneously occluded GIA secondary to gradual growth of the GIA, continuously progressed aneurysmal thrombosis, complete aneurysmal calcification and complete occlusion of the parent artery-the right internal carotid artery (RICA). CASE SUMMARY A 72-year-old female patient complained of sudden pain in her right eye upon admission to our hospital. She had been diagnosed with a GIA [30 mm (axial) × 38 mm (coronal) × 28 mm (sagittal)] containing an aneurysmal thrombus located in the cavernous sinus segment of RICA diagnosed by magnetic resonance imaging (MRI), enhanced MRI, and magnetic resonance angiography more than 14 years ago. Later, with slow growth of the cavernous carotid GIA, aneurysmal thrombosis progressed continuously, spontaneous occlusion of the RICA, complete aneurysmal calcification, and occlusion of the GIA occurred gradually. She had no history of subarachnoid hemorrhage but missed the chance for endovascular therapy at an early stage. As a result, she was left with severe permanent sequelae from the injuries to the right cranial nerves II, III, IV, V1/V2, and VI. CONCLUSION The risk of rupture of the cavernous carotid GIAs was relatively low and possibly further be reduced by the stasis flow and spontaneous occlusion of the parent artery internal carotid artery (ICA) induced by the mass effect of the cavernous carotid GIAs and the extremely rare aneurysmal calcification. However, nowadays, it is advisable to recommend early endovascular treatment for the cavernous carotid GIAs to prevent injuries to the surrounding intracranial nerves and occlusion of the ICA, mainly caused by the mass effect of the cavernous carotid GIAs.
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Affiliation(s)
- Ming-Xi Wang
- School of Medicine, Huaqiao University, Xiamen 361021, Fujian Province, China
| | - Qing-Bin Nie
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing 100853, China
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Fujii T, Teranishi K, Mitome-Mishima Y, Kitamura T, Wada K, Kondo A, Oishi H. It Is Necessary to Pay Attention to Where the Pcom Originate from the Aneurysm to Treat with FD. Asian J Neurosurg 2024; 19:168-173. [PMID: 38974449 PMCID: PMC11226285 DOI: 10.1055/s-0043-1778085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/09/2024] Open
Abstract
Objective With the expansion of indications of flow diverter (FD) for cerebral aneurysms, FD placement for posterior communicating artery (Pcom) aneurysms has been approved. However, it is controversial whether Pcom aneurysms should be treated with FD or not. In this study, we report the outcome of FD treatment for Pcom aneurysms in Japan. Materials and Methods We retrospectively analyzed 36 patients with 38 aneurysms treated with FD placement for Pcom aneurysms between 2015 and 2021 in our hospital. We divided our cases into complete occlusion (CO) and non-CO groups. And we extracted contributing factors to CO using multivariate analysis. We also compared the complications rate among the three types of FDs. Results CO was obtained in 29 cases (79.3%), and complications were observed in 3 cases (7.9%). Multivariate analysis revealed that the type of Pcom branch from the aneurysmal dome was a significant factor contributing to CO (odds ratio: 0.0052, 95% confidence interval 0.000048-0.584, p = 0.029). In terms of complications, complication rate was significantly higher in the Flow-Redirection Endoluminal Device (FRED) group ( p = 0.0491). Conclusion The outcome for Pcom aneurysms treated by FD was acceptable. When treating, we must pay attention to where Pcom originates. Achieving CO with FD is difficult for aneurysms where the Pcom branches from the dome. Furthermore, when treating Pcom aneurysms with FRED, it is necessary to be careful about thromboembolic complications.
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Affiliation(s)
- Takashi Fujii
- Department of Neuroendovascular Therapy, Juntendo University, Graduate School of Medicine, Tokyo, Japan
- Department of Neurosurgery, National Defense Medical College, Saitama, Japan
| | - Kohsuke Teranishi
- Department of Neurosurgery, Juntendo University, Graduate School of Medicine, Tokyo, Japan
| | - Yumiko Mitome-Mishima
- Department of Neurosurgery, National Defense Medical College, Saitama, Japan
- Department of Neurosurgery, Juntendo University, Graduate School of Medicine, Tokyo, Japan
| | - Takayuki Kitamura
- Department of Neurosurgery, Juntendo University, Graduate School of Medicine, Tokyo, Japan
| | - Kojiro Wada
- Department of Neurosurgery, National Defense Medical College, Saitama, Japan
| | - Akihide Kondo
- Department of Neurosurgery, Juntendo University, Graduate School of Medicine, Tokyo, Japan
| | - Hidenori Oishi
- Department of Neuroendovascular Therapy, Juntendo University, Graduate School of Medicine, Tokyo, Japan
- Department of Neurosurgery, Juntendo University, Graduate School of Medicine, Tokyo, Japan
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Mosteiro A, Pedrosa L, Codes M, Reyes L, Werner M, Amaro S, Enseñat J, Rodríguez-Hernández A, Aalbers M, Boogaarts J, Torné R. Microsurgical and endovascular treatment of large and giant aneurysms of the anterior circulation: A systematic review. BRAIN & SPINE 2024; 4:102838. [PMID: 39071454 PMCID: PMC11279635 DOI: 10.1016/j.bas.2024.102838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 05/20/2024] [Accepted: 05/22/2024] [Indexed: 07/30/2024]
Abstract
Introduction Large and Giant intracranial aneurysms (LGIAs) have become the paradigm for which endovascular techniques do not provide satisfactory results. Yet, microsurgery is followed by non-negligible rates of morbimortality. This scenario may have changed since the introduction of flow-diversion devices. Research question Contemporary and standardised revision on microsurgical and endovascular results, with emphasis on anterior circulation LGIAs. Materials and methods A systematic literature search was conducted in two databases (PubMed and Embase) on treatment outcomes of LGIAs of the anterior circulation, after the introduction of flow-diverters 2008/01/01, till 2023/05/20. Small case series (<5 cases), series including >15% of posterior circulation aneurysms, and studies not reporting clinical and/or angiographic outcomes were excluded. Results 44 relevant studies (observational cohorts) were identified, including 2923 LGIAs predominantly from anterior circulation. Mean follow-up 22 (±20) months. 1494 (51%) LGIAs were treated endovascularly and 1427 (49%) microsurgically. According to the random effects model, pooled rates of favourable clinical outcomes were 85.8% (CI 95% 82.6-88.4), complete occlusion 69.4% (CI 95% 63.7-7.46), complications 19.6% (CI 95%16-23.9) and mortality 5.6% (CI 95% 4.4-7.1). Focusing on type of treatment, occlusion rates are higher with microsurgical (842/993, 85% vs 874/1,299, 67%), although good outcomes are slightly more frequent with endovascular (1045/1,135, 92% vs 1120/1,294, 87%). Discussion and conclusions According to contemporary data about occlusion rates, functional outcomes, and complications, primary or secondary treatment of LGIAs of the anterior circulation seems justified. Microsurgical occlusion rates are higher in LGIAs. An expert consensus on reporting complications and management strategies is warranted.
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Affiliation(s)
- Alejandra Mosteiro
- Department of Neurosurgery, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
| | - Leire Pedrosa
- Department of Neurosurgery, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
- IDIBAPS Biomedical Research Institute, Barcelona, Spain
| | - Marta Codes
- Department of Neurosurgery, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
| | - Luís Reyes
- Department of Neurosurgery, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
| | - Mariano Werner
- Interventional Neuroradiology Department, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Sergio Amaro
- IDIBAPS Biomedical Research Institute, Barcelona, Spain
- Comprehensive Stroke Unit, Neurology, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Joaquim Enseñat
- Department of Neurosurgery, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
- IDIBAPS Biomedical Research Institute, Barcelona, Spain
| | | | - Marlien Aalbers
- Department of Neurosurgery, Radboud University Medical Center, Nijmegen, Gelderland, the Netherlands
| | - Jeroen Boogaarts
- Department of Neurosurgery, Radboud University Medical Center, Nijmegen, Gelderland, the Netherlands
| | - Ramon Torné
- Department of Neurosurgery, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
- IDIBAPS Biomedical Research Institute, Barcelona, Spain
- Interventional Neuroradiology Department, Hospital Clinic of Barcelona, Barcelona, Spain
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Jee TK, Yeon JY, Kim KH, Kim JS, Jeon P. Evaluation of the Significance of Persistent Remnant Filling and Enlargement After Flow Diversion for Intracranial Aneurysms. World Neurosurg 2024; 184:e144-e153. [PMID: 38253178 DOI: 10.1016/j.wneu.2024.01.073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Accepted: 01/13/2024] [Indexed: 01/24/2024]
Abstract
BACKGROUND This study aimed to evaluate the clinical course after flow diversion (FD) treatment with a focus on aneurysms with remnant sac filling, by analyzing angiographic outcomes, aneurysm volume, and clinical events. METHODS We retrospectively reviewed the medical records of 61 patients who underwent FD for intracranial aneurysms between July 2014 and June 2021. RESULTS The majority of aneurysms (52.5%) were located in the internal carotid artery, with a median diameter of 16.6 mm and neck size of 9.3 mm. Remnant filling was observed in 17 aneurysms (27.9%) more than 18 months after FD, 10 (16.4%) of these aneurysms underwent enlargement, which occurred only in cases with subtotal filling or entry remnant states. Eleven patients experienced major adverse events, and three exhibited unfavorable functional outcomes. The incidence of major adverse events and unfavorable functional outcomes was significantly higher in the aneurysm enlargement group than that in the no-filling or stable remnant filling groups (P < 0.001). Aneurysmal diameter and the presence of incorporated branches were independent predictors of aneurysm enlargement, while the presence of incorporated branches was the only independent predictor of persistent remnant filling. CONCLUSIONS Aneurysm enlargement after FD is not uncommon, particularly when the aneurysm is large, has incorporated vessels, or does not undergo occlusion within 12 months, often culminating in major adverse events and unfavorable functional outcomes. In addition to investigating angiographic results, it is necessary to evaluate the changes in aneurysm size and clinical events when assessing the efficacy of FD.
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Affiliation(s)
- Tae Keun Jee
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Je Young Yeon
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Keon Ha Kim
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jong-Soo Kim
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Pyoung Jeon
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
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Zhao Y, Lu J, Zhang H, Li T, Song D, Guan S, Maimaitili A, Wang Y, Feng W, Wang Y, Wan J, Mao G, Shi H, Yang X, Liu J, Zhao Y. Pipeline Embolization Device for intracranial aneurysms presenting with mass effect: a large Chinese cohort. Stroke Vasc Neurol 2024; 9:50-58. [PMID: 37295810 PMCID: PMC10956105 DOI: 10.1136/svn-2022-002213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 05/18/2023] [Indexed: 06/12/2023] Open
Abstract
BACKGROUND Unruptured intracranial aneurysm treatment aims to reduce the risk of aneurysm rupture and bleeding, relieves symptoms and improve the quality of life for patients. This study aimed to assess the safety and efficacy of Pipeline Embolization Device (PED, Covidien/Medtronic, Irvine, CA) treatment for intracranial aneurysms presenting with mass effect in real-world settings. METHODS We selected patients from the PED in China Post-Market Multi-Center Registry Study with mass effect presentation. The study endpoints included postoperative mass effect deterioration and mass effect relief at follow-up (3-36 months). We conducted multivariate analysis to identify factors associated with mass effect relief. Subgroup analyses by aneurysm location, size and form were also performed. RESULTS This study included 218 patients with a mean age of 54.3±11.8 years and a female predominance of 74.0% (162/218). The postoperative mass effect deterioration rate was 9.6% (21/218). During a median follow-up period of 8.4 months, the mass effect relief rate was 71.6% (156/218). Notably, immediate aneurysm occlusion following treatment was significantly associated with mass effect relief (OR 0.392, 95% CI, 0.170 to 0.907, p=0.029). Subgroup analysis demonstrated that adjunctive coiling contributed to mass effect relief in cavernous aneurysms, while dense embolism impeded symptom relief in aneurysms<10 mm and saccular aneurysms. CONCLUSIONS Our data confirmed the efficacy of PED in relieving mass effect. The findings of this study provide support for endovascular treatment to alleviate mass effect in unruptured intracranial aneurysms. TRIAL REGISTRATION NUMBER NCT03831672.
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Affiliation(s)
- Yang Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Neurosurgery, Peking University International Hospital, Beijing, China
| | - Junlin Lu
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Hongqi Zhang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Tianxiao Li
- Department of Interventional Neuroradiology, Zhengzhou University People's Hospital, Zhengzhou, Henan, China
| | - Donglei Song
- Department of Neurosurgery, Shanghai Donglei Brain Hospital, Shanghai, China
| | - Sheng Guan
- Department of Interventional Neuroradiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Aisha Maimaitili
- Department of Neurosurgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Yunyan Wang
- Department of Neurosurgery, Qilu Hospital of Shandong University Qingdao, Jinan, Shandong, China
| | - Wenfeng Feng
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Yang Wang
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Jieqing Wan
- Department of Neurosurgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Guohua Mao
- Department of Neurosurgery, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Huaizhang Shi
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Xinjian Yang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jianmin Liu
- Department of Neurosurgery, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Yuanli Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Akiyama R, Ishii A, Kikuchi T, Okawa M, Yamao Y, Abekura Y, Ono I, Sasaki N, Tsuji H, Matsukawa S, Miyamoto S. Predictors of aneurysm shrinkage after flow diversion treatment for internal carotid artery aneurysms: quantitative volume analysis with MRI. Front Neurol 2023; 14:1266460. [PMID: 38187156 PMCID: PMC10768176 DOI: 10.3389/fneur.2023.1266460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 12/08/2023] [Indexed: 01/09/2024] Open
Abstract
Background and purpose Although aneurysm shrinkage often occurs after flow diversion treatment for intracranial aneurysms, no reports have addressed the factors associated with aneurysm shrinkage. Materials and methods This retrospective single-center study was performed to examine patients with unruptured internal carotid artery aneurysms who were treated using flow diversion and followed up by imaging for at least 12 months. The study outcome was aneurysm shrinkage (volume reduction of ≥10%) 12 months after treatment. Aneurysm volume was quantitatively assessed using the MRIcroGL software. Patient and aneurysm characteristics were statistically analyzed. Results This study involved 81 patients with 88 aneurysms. At the 6 months, 12 months, and last follow-ups, the proportion of aneurysms that had shrunk was 50, 64, and 65%, respectively. No adjunctive coiling (odds ratio, 56.7; 95% confidence interval, 7.03-457.21; p < 0.001) and aneurysm occlusion (odds ratio, 90.7; 95% confidence interval, 8.32-988.66; p < 0.001) were significantly associated with aneurysm shrinkage. In patients treated by flow diversion with adjunctive coiling, only the volume embolization rate was a factor significantly associated with aneurysm shrinkage (p < 0.001). Its cutoff value was 15.5% according to the receiver operating characteristic curve analysis (area under the curve, 0.87; sensitivity, 0.87; specificity, 0.83). Conclusion The rate of aneurysm shrinkage after flow diversion increased during the first 12 months after treatment, but not thereafter. No adjunctive coiling and aneurysm occlusion were predictors of aneurysm shrinkage, respectively. If adjunctive coiling is required, a volume embolization rate of ≤15.5% may be suggested for aneurysm regression.
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Affiliation(s)
- Ryo Akiyama
- Department of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Akira Ishii
- Department of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Takayuki Kikuchi
- Department of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Masakazu Okawa
- Department of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yukihiro Yamao
- Department of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yu Abekura
- Department of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Isao Ono
- Department of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
- Department of Neurosurgery, Hikone Municipal Hospital, Hikone, Japan
| | - Natsuhi Sasaki
- Department of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Hirofumi Tsuji
- Department of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - So Matsukawa
- Department of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Susumu Miyamoto
- Department of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
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10
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Kaiser DPO, Cuberi A, Linn J, Gawlitza M. Flow diversion for compressive unruptured internal carotid artery aneurysms with neuro-ophthalmological symptoms: a systematic review and meta-analysis. J Neurointerv Surg 2023; 15:892-897. [PMID: 35918130 PMCID: PMC10447391 DOI: 10.1136/jnis-2022-019249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 07/20/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Data on the safety and efficacy of flow diverters (FD) for the treatment of unruptured internal carotid artery (ICA) aneurysms with compressive neuro-ophthalmological symptoms (NOS) are scarce and comprise mainly small case series. METHODS We performed a search of three databases and included series with ≥10 patients, with unruptured aneurysms of the ICA and NOS, treated with FD. Random-effects analysis of treatment results and safety was performed. RESULTS A total of 22 studies reporting on 594 patients were included. Pooled proportions of NOS recovery, improvement, transient and permanent worsening were: 47.4% (95% CI 35.0% to 60.1%); 74.5% (95% CI 67.9% to 80.2%); 7.1% (95% CI 3.3% to 14.7%); and 4.9% (95% CI 3.2% to 7.4%), respectively. Rates of complete recovery and improvement in patients with isolated visual symptoms were 30.6% (95% CI 12.5% to 57.7%) and 56.6% (95% CI 42.3% to 69.9%). Isolated oculomotor symptoms recovered completely in 47.8% (95% CI 29.9% to 66.3%) and improved in 78% (95% CI 69.2% to 84.9%). Morbidity occurred in 5% (95% CI 2.8% to 9%) and mortality in 3.9% (95% CI 2% to 7.5%) of patients. An increased likelihood of symptom improvement was observed when treatment was performed early (<1 month) after symptom onset (OR=11.22, 95% CI 3.9% to 32.5%). CONCLUSION Flow diversion promotes recovery or improvement of compressive symptoms in a large proportion of patients but is associated with significant rates of morbidity and mortality. Transient and permanent NOS worsening is not uncommon. Early treatment is of utmost importance, as it increases the likelihood of symptom improvement more than 10-fold.
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Affiliation(s)
- Daniel P O Kaiser
- Department of Neuroradiology, University Hospital Carl Gustav Carus, Dresden, Germany
- EKFZ for Digital Health, Dresden University of Technology, Dresden, Germany
| | - Ani Cuberi
- Department of Radiology, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Jennifer Linn
- Department of Neuroradiology, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Matthias Gawlitza
- Department of Neuroradiology, University Hospital Carl Gustav Carus, Dresden, Germany
- EKFZ for Digital Health, Dresden University of Technology, Dresden, Germany
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11
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Akiyama R, Ishii A, Kikuchi T, Okawa M, Yamao Y, Abekura Y, Ono I, Sasaki N, Tsuji H, Imamura H, Hatano T, Sakai N, Miyamoto S. Onset-to-treatment time and aneurysmal regression predict improvement of cranial neuropathy after flow diversion treatment in patients with symptomatic internal carotid artery aneurysms. J Neurointerv Surg 2023; 15:886-891. [PMID: 35853697 PMCID: PMC10447392 DOI: 10.1136/jnis-2022-019202] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 07/10/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Although flow diversion plays a pivotal role in treating internal carotid artery aneurysms presenting with cranial neuropathy, predictors of symptom improvement have not been established. OBJECTIVE To investigate improvement of symptoms after flow diversion treatment in patients with internal carotid artery aneurysms causing cranial neuropathy, with sufficient follow-up period. Additionally, to examine factors associated with improvement of symptoms. METHODS This retrospective multicenter study examined patients with unruptured internal carotid artery aneurysms presenting with cranial neuropathy who were treated using flow diversion and followed up for at least 12 months. Study outcomes were transient worsening of symptoms and symptom status 12 months after treatment. Patient and aneurysm characteristics were statistically analyzed. RESULTS Seventy-seven patients were included. Data needed for outcome analysis were available for 66 patients. At the 1-, 3-, 6-, 12-month, and last follow-ups, the proportion of patients with resolved or improved symptoms was 26% (20/77), 51% (39/77), 74% (57/77), 83% (64/77), and 79%(62/77), respectively. Symptom onset-to-treatment time <6 months (OR=24.2; 95% CI 3.09 to 188.84; p=0.002) and aneurysmal regression (OR=23.1; 95% CI 1.97 to 271.75; p=0.012) were significantly associated with symptom improvement. Transient symptom worsening and worse symptoms at 12 months occurred in 19/77 (25%) and 2/77 (3%) patients, respectively. CONCLUSIONS The rate of cranial neuropathy symptom improvement after flow diversion increased over the first 12 months after treatment, but not thereafter. Treatment within 6 months of symptom onset and aneurysmal regression were predictors of symptom improvement.
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Affiliation(s)
- Ryo Akiyama
- Department of Neurosurgery, Kyoto University Graduate School of Medicine Faculty of Medicine, Kyoto, Kyoto, Japan
| | - Akira Ishii
- Department of Neurosurgery, Kyoto University Graduate School of Medicine Faculty of Medicine, Kyoto, Kyoto, Japan
| | - Takayuki Kikuchi
- Department of Neurosurgery, Kyoto University Graduate School of Medicine Faculty of Medicine, Kyoto, Kyoto, Japan
| | - Masakazu Okawa
- Department of Neurosurgery, Kyoto University Graduate School of Medicine Faculty of Medicine, Kyoto, Kyoto, Japan
| | - Yukihiro Yamao
- Department of Neurosurgery, Kyoto University Graduate School of Medicine Faculty of Medicine, Kyoto, Kyoto, Japan
| | - Yu Abekura
- Department of Neurosurgery, Kyoto University Graduate School of Medicine Faculty of Medicine, Kyoto, Kyoto, Japan
| | - Isao Ono
- Department of Neurosurgery, Kyoto University Graduate School of Medicine Faculty of Medicine, Kyoto, Kyoto, Japan
| | - Natsuhi Sasaki
- Department of Neurosurgery, Kyoto University Graduate School of Medicine Faculty of Medicine, Kyoto, Kyoto, Japan
| | - Hirofumi Tsuji
- Department of Neurosurgery, Kyoto University Graduate School of Medicine Faculty of Medicine, Kyoto, Kyoto, Japan
| | - Hirotoshi Imamura
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Taketo Hatano
- Department of Neurosurgery, Kokura Memorial Hospital, Kitakyushu, Fukuoka, Japan
| | - Nobuyuki Sakai
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Susumu Miyamoto
- Department of Neurosurgery, Kyoto University Graduate School of Medicine Faculty of Medicine, Kyoto, Kyoto, Japan
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12
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Zhang H, Liu W, Gu Y, Li A, Zhang D. Dolenc approach for clipping of giant C6 and C7 segment aneurysms of the internal carotid artery. Front Surg 2023; 10:1222386. [PMID: 37671032 PMCID: PMC10475532 DOI: 10.3389/fsurg.2023.1222386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Accepted: 08/01/2023] [Indexed: 09/07/2023] Open
Abstract
Objective Surgical treatment for giant aneurysms of the ICA-ophthalmic segment (C6) and communicating artery segment (C7) is a challenge for neurosurgeons because of their high risks and poor outcomes. We aim to explore the advantages and disadvantages of the Dolenc approach in the treatment of giant C6-C7 segment aneurysms. Methods We retrospectively reviewed the clinical data of 13 cases with giant C6 aneurysms and 4 cases with giant C7 aneurysms treated with the Dolenc approach. Results All 17 cases of aneurysms were clipped successfully using the Dolenc approach, of which, 1 case with ipsilateral MCA occlusion underwent extracranial-intracranial artery bypass after the aneurysm clipping. Regarding clinical outcomes, six out of nine cases with preoperative visual impairment improved after surgery, two cases saw no change, and one case deteriorated. Of all the cases, one had new-onset vision loss, four had new-onset oculomotor paralysis, three had surgical side cerebral infarction, and two had diabetes insipidus. DSA or CTA examination within 2 weeks after surgery showed that all aneurysms were completely clipped without residual. After a follow-up of 9-12 months, 17 patients were evaluated based on GOS and CTA examination. A total of 14 cases had GOS 5 scores, 2 cases had GOS 4 scores, 1 case had GOS 2 scores, and no cases had death. None of the patients had recurrence based on CTA examinations. Conclusion Through the Dolenc approach, we could achieve more operation space and expose clinoid segments for temporary occlusion. Therefore, the Dolenc approach was shown to be a safe, effective, and feasible treatment for giant C6-C7 aneurysms.
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Affiliation(s)
- Hongwei Zhang
- Department of Neurosurgery, The Affiliated Lianyungang Hospital of Xuzhou Medical University, Lianyungang, China
- Department of Neurosurgery, Beijing Tiantan Hospital Affiliated to Capital Medical University, Beijing, China
| | - Wei Liu
- Department of Neurosurgery, Beijing Tiantan Hospital Affiliated to Capital Medical University, Beijing, China
| | - Yan Gu
- Department of Neurosurgery, The Affiliated Lianyungang Hospital of Xuzhou Medical University, Lianyungang, China
| | - Aimin Li
- Department of Neurosurgery, The Affiliated Lianyungang Hospital of Xuzhou Medical University, Lianyungang, China
| | - Dong Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital Affiliated to Capital Medical University, Beijing, China
- Department of Neurosurgery, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
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13
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Nishimoto K, Ozaki T, Kidani T, Nakajima S, Kanemura Y, Yamazaki H, Fujinaka T. Flow Diverter Stenting for Symptomatic Intracranial Internal Carotid Artery Aneurysms: Clinical Outcomes and Factors for Symptom Improvement. Neurol Med Chir (Tokyo) 2023; 63:343-349. [PMID: 37286482 PMCID: PMC10482490 DOI: 10.2176/jns-nmc.2022-0389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 03/22/2023] [Indexed: 06/09/2023] Open
Abstract
Flow diverter (FD) stenting is expected to improve cranial nerve symptoms caused by aneurysms via the theoretical reduction of the mass effect by promoting spontaneous thrombosis through the flow diversion effect. However, the factors involved in symptom improvement after treatment remain unclear. This study was performed to identify factors for symptom improvement after FD stenting and the symptom improvement rate of each impaired cranial nerve. We retrospectively evaluated 33 patients who underwent FD stenting for symptomatic internal carotid artery aneurysms at our institution from January 2016 to June 2021. Twenty-three (69.7%) patients had resolved or improved symptoms after 1 year of treatment. The optic nerve was affected in 12 patients; the oculomotor nerve, in 16; the trigeminal nerve, in 2; and the abducens nerve, in 13. There was no statistically significant difference in the symptom improvement rate of each impaired cranial nerve. The patients were classified into the improved and nonimproved groups based on their symptoms after 1 year of treatment, and the factors related to the symptoms were analyzed. The time from onset to treatment was significantly shorter in the improved group than in the nonimproved group (197.1 and 800 days, respectively; p = 0.023). There were no significant differences in age, aneurysm diameter, adjunctive coil embolization, partial thrombosis, change in mass diameter on magnetic resonance imaging, or aneurysm occlusion rate on angiography between the two groups. These results suggest that early treatment after the onset of aneurysm-induced cranial neuropathies increases the likelihood of symptom improvement.
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Affiliation(s)
- Keisuke Nishimoto
- Department of Neurosurgery, National Hospital Organization, Osaka National Hospital
- Department of Neurosurgery, Osaka University Graduate School of Medicine
| | - Tomohiko Ozaki
- Department of Neurosurgery, National Hospital Organization, Osaka National Hospital
| | - Tomoki Kidani
- Department of Neurosurgery, National Hospital Organization, Osaka National Hospital
| | - Shin Nakajima
- Department of Neurosurgery, National Hospital Organization, Osaka National Hospital
| | - Yonehiro Kanemura
- Department of Neurosurgery, National Hospital Organization, Osaka National Hospital
- Department of Biomedical Research and Innovation, Institute for Clinical Research, National Hospital Organization Osaka National Hospital
| | - Hiroki Yamazaki
- Department of Neurosurgery, National Hospital Organization, Osaka National Hospital
| | - Toshiyuki Fujinaka
- Department of Neurosurgery, National Hospital Organization, Osaka National Hospital
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14
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Hasebe A, Nakahara I, Matsumoto S, Morioka J, Tanabe J, Watanabe S, Suyama K, Ishihara T, Hirose Y. Factors influencing early obliteration during flow diverter treatment of cerebral aneurysms: Establishment of an early obliteration inhibition score. FUJITA MEDICAL JOURNAL 2023; 9:240-245. [PMID: 37554932 PMCID: PMC10405891 DOI: 10.20407/fmj.2022-033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 10/20/2022] [Indexed: 08/10/2023]
Abstract
OBJECTIVE This retrospective study aimed to investigate factors associated with inhibition of early aneurysm obliteration after flow diverter (FD) treatment. We also created the early obliteration inhibition (EOI) score for pre-operative evaluation. METHODS We examined 110 cerebral aneurysms in 104 patients who underwent FD treatment. The following parameters were investigated: age, sex, symptoms, aneurysm location and type, maximum aneurysm diameter, parent vessel diameter, neck diameter, and dome-neck ratio. We also noted aneurysm location relative to the curvature of the parent artery and any branches arising from the aneurysm dome. Procedural factors such as FD diameter and length, number of FDs placed, type of FD, and use of adjunctive coiling were also investigated. Aneurysm obliteration was evaluated using digital subtraction angiography 3 months after the procedure. Adequate obliteration was defined as grade C or D on the O'Kelly-Marotta scale. RESULTS The following factors inhibited early obliteration: 1) extradural location, 2) saccular aneurysm, 3) aneurysm neck located at the outer convexity of the parent artery, and 4) arterial branch arising from the aneurysm dome. Odds ratios were used to create an EOI score. Receiver operating characteristic curve analysis showed that the optimal cut-off EOI score for adequate obliteration was 1.5 (area under the curve, 0.81; 95% confidence interval, 0.73-0.9; sensitivity, 0.9; specificity, 0.57). CONCLUSION The EOI score, which is based on factors that inhibit early obliteration, may predict early treatment outcomes of FD placement.
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Affiliation(s)
- Akiko Hasebe
- Department of Comprehensive Strokology, Fujita Health University, School of Medicine, Toyoake, Aichi, Japan
| | - Ichiro Nakahara
- Department of Comprehensive Strokology, Fujita Health University, School of Medicine, Toyoake, Aichi, Japan
| | - Shoji Matsumoto
- Department of Comprehensive Strokology, Fujita Health University, School of Medicine, Toyoake, Aichi, Japan
| | - Jun Morioka
- Department of Comprehensive Strokology, Fujita Health University, School of Medicine, Toyoake, Aichi, Japan
| | - Jun Tanabe
- Department of Comprehensive Strokology, Fujita Health University, School of Medicine, Toyoake, Aichi, Japan
| | - Sadayoshi Watanabe
- Department of Comprehensive Strokology, Fujita Health University, School of Medicine, Toyoake, Aichi, Japan
| | - Kenichiro Suyama
- Department of Comprehensive Strokology, Fujita Health University, School of Medicine, Toyoake, Aichi, Japan
| | - Takuma Ishihara
- Innovative and Clinical Research Promotion Center, Gifu University Hospital, Gifu, Gifu, Japan
| | - Yuichi Hirose
- Department of Neurosurgery, Fujita Health University, Graduate School of Medicine, Toyoake, Aichi, Japan
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15
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Sakaguchi M, Yamaguchi K, Funatsu T, Akihiro N, Moteki Y, Eguchi S, Ishikawa T, Kawamata T. Bilateral symptomatic large cavernous carotid artery aneurysms treated by extracranial-intracranial bypass with parent artery occlusion. Clin Neurol Neurosurg 2023; 229:107758. [PMID: 37163929 DOI: 10.1016/j.clineuro.2023.107758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 05/01/2023] [Accepted: 05/03/2023] [Indexed: 05/12/2023]
Abstract
Bilateral large cavernous sinus internal carotid aneurysms (CCAs) occur very rarely. While the choice of treatment method is important, the timing of contralateral side treatment is equally important. We herein report the case of a 72-year-old woman who presented with progressive bilateral visual impairment and was treated by two-stage. First, the left CCAs had been treated, and the aneurysm was thrombosed, but her left visual acuity did not recover; the right CCA was becoming larger 2 years later, and her right visual acuity began worsening. The right CCAs was treated by almost same method. Her right visual acuity improved compared with the second preoperative findings. Our case findings suggest the importance of considering the appropriate timing to avoid symptom aggravation in patients with bilateral CCAs.
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Affiliation(s)
- Makiko Sakaguchi
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Koji Yamaguchi
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan.
| | - Takayuki Funatsu
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Niwa Akihiro
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Yosuke Moteki
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Seiichiro Eguchi
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Tatsuya Ishikawa
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Takakazu Kawamata
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
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16
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Kitamura T, Fujii T, Yatomi K, Teranishi K, Mitome-Mishima Y, Oishi H. Safety and efficacy of pipeline embolization device treatments for intradural internal carotid artery aneurysms in a single center in a Japanese population. Surg Neurol Int 2023; 14:92. [PMID: 37025526 PMCID: PMC10070317 DOI: 10.25259/sni_1165_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 02/25/2023] [Indexed: 03/19/2023] Open
Abstract
Background:
The pipeline embolization device (PED) is the most common flow diverter device in the world. To date, there have been no reports of treatment outcomes specific to intradural internal carotid artery (ICA) aneurysms. The safety and efficacy of the PED treatments for intradural ICA aneurysms are reported.
Methods:
131 patients with 133 aneurysms underwent PED treatments for intradural ICA aneurysms. The mean aneurysm dome size and neck length were 12.7 ± 4.3 mm and 6.1 ± 2.2 mm, respectively. We used adjunctive endosaccular coil embolization for 88 aneurysms (66.2%). A total of 113 aneurysms (85%) were angiographically followed up 6 months following the procedure, and 93 aneurysms (69.9%) were followed up for 1 year.
Results:
The angiographic outcome at 6 months showed that 94 (83.2%) aneurysms had O’Kelly-Marotta (OKM) grade D, 6 (5.3%) had C, 10 (8.8%) had B, and 3 (2.7%) had A. At 1 year, 82 (88.2%) aneurysms had OKM grade D, 6 (6.5%) had C, 3 (3.2%) had B, and 2 (2.2%) had A. Multivariate analysis showed that aneurysm neck size and adjunctive coiling were statistically significant in aneurysm occlusion status. Major morbidity modified Rankin Scale >2 and mortality rates related to procedures were 3.0% and 0%, respectively. Delayed aneurysm ruptures were not observed.
Conclusion:
These results reveal that PED treatment of intradural ICA aneurysms is safe and efficacious. The combined use of adjunctive coil embolization not only prevents delayed aneurysm ruptures but also contributes to an increase in the rate of complete occlusion.
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Affiliation(s)
- Takayuki Kitamura
- Department of Neuroendovascular Therapy and Neurosurgery, Juntendo University Faculty of Medicine, Bunkyo-ku, Tokyo, Japan
| | - Takashi Fujii
- Department of Neuroendovascular Therapy, Juntendo University Faculty of Medicine, Bunkyo-ku, Tokyo, Japan
| | - Kenji Yatomi
- Department of Neurosurgery, Juntendo University Faculty of Medicine, Bunkyo-ku, Tokyo, Japan
| | - Kohsuke Teranishi
- Department of Neurosurgery, Juntendo University Faculty of Medicine, Bunkyo-ku, Tokyo, Japan
| | - Yumiko Mitome-Mishima
- Department of Neurosurgery, Juntendo University Faculty of Medicine, Bunkyo-ku, Tokyo, Japan
| | - Hidenori Oishi
- Department of Neuroendovascular Therapy and Neurosurgery, Juntendo University Faculty of Medicine, Bunkyo-ku, Tokyo, Japan
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17
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Arai S, Fujii T, Teranishi K, Nonaka S, Kitamura T, Mitome-Mishima Y, Kondo A, Oishi H. Pipeline Flex with Shield Technology Placement for Small- and Medium-sized Aneurysms Achieves Early Complete Occlusion. Neurol Med Chir (Tokyo) 2023; 63:58-64. [PMID: 36543205 PMCID: PMC9995145 DOI: 10.2176/jns-nmc.2022-0217] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
The flow diverter has been shown to be a safe and effective device for large cerebral aneurysms in the proximal internal carotid artery (ICA). Recently, its indication has been expanded to small- and medium-sized cerebral aneurysms in the distal segment of the ICA. In this study, we report a single-center, retrospective investigation of the safety and efficacy of the Pipeline Flex device to treat these aneurysms. Of the patients who underwent Pipeline implantation for small- and medium-sized ICA aneurysms (≤12 mm) at our hospital between July 2013 and October 2021, 102 patients with 104 aneurysms were included in this study. The mean age of the patients was 57.7 ± 12.1 years, and 94 (90.4%) were female. The mean aneurysmal dome diameter was 9.2 ± 2.3 mm, the mean neck diameter was 5.3 ± 1.6 mm, and the mean dome-to-neck ratio was 1.8 ± 0.5. Twenty-five patients (24.0%) had incorporated vessels from the aneurysm. Complete occlusion of the aneurysms was obtained in 96 patients (92.3%). There were no cases of parent artery stenosis or major stroke after the procedure. Absence of incorporated vessel from the aneurysm dome and adjunctive coil embolization are statistically significant factors indicating complete occlusion in multivariate analysis. The time to complete occlusion was determined earlier with the use of the Pipeline Shield (p = 0.0386) and with adjunctive coils (p = 0.0025). We showed that Pipeline implantation for small- and medium-sized aneurysms was safe and highly effective.
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Affiliation(s)
- Sho Arai
- Department of Neurosurgery, Graduate School of Medicine, Juntendo University
| | - Takashi Fujii
- Department of Neuroendovascular Therapy, Graduate School of Medicine, Juntendo University
| | - Kohsuke Teranishi
- Department of Neurosurgery, Graduate School of Medicine, Juntendo University
| | - Senshu Nonaka
- Department of Neurosurgery, Graduate School of Medicine, Juntendo University
| | - Takayuki Kitamura
- Department of Neurosurgery, Graduate School of Medicine, Juntendo University
| | | | - Akihide Kondo
- Department of Neurosurgery, Graduate School of Medicine, Juntendo University
| | - Hidenori Oishi
- Department of Neurosurgery, Graduate School of Medicine, Juntendo University.,Department of Neuroendovascular Therapy, Graduate School of Medicine, Juntendo University
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18
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Simgen A, Roth C, Kulikovski J, Papanagiotou P, Roumia S, Dietrich P, Mühl-Benninghaus R, Kettner M, Reith W, Yilmaz U. Endovascular treatment of unruptured intracranial aneurysms with flow diverters: A retrospective long-term single center analysis. Neuroradiol J 2023; 36:76-85. [PMID: 35695038 PMCID: PMC9893170 DOI: 10.1177/19714009221108678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
PURPOSE The introduction of flow diverters (FDs) in 2007 greatly enhanced the treatment of intracranial aneurysms. Here, we present our long-term clinical experience in treating unruptured intracranial aneurysms with FDs. METHODS 107 patients with unruptured aneurysms and treated with an FD between 2010 and 2019 were retrospectively reviewed. Aneurysm occlusion, procedural complications, and clinical outcome were evaluated. RESULTS Angiographic follow-up was available for 93 patients with a mean long-term follow-up time of 28.4 ± 21.6 months. Additional coiling was performed in 15.1% of patients (n = 14). Adequate aneurysm occlusion (Kamran grades 3 and 4) at long-term follow-up was achieved in 94.6% of patients (n = 88). 3.2% (n = 3) required endovascular retreatment since the last follow-up showed a lack of aneurysm occlusion (Kamran grade 0) due to a foreshortening of the FD. Incomplete opening of the FD and parent vessel occlusion was seen in 1.1% (n = 1) and 3.2% (n = 3) of patients, respectively. In-stent stenosis was observed in 57% (n = 53) of cases at short-term follow-up and 22.6% (n = 21) at long-term, which were moderate and asymptomatic overall. In-stent stenosis decreased significantly between short- and long-term follow-ups (31.4 ± 17.0% vs 9.7 ± 13.6%, respectively; p ≤ 0.001). Thromboembolic and hemorrhagic events occurred in 7.5% (n = 7) and 1.1% (n = 1) of patients, respectively. Good clinical outcome (modified Rankin scale: 0-2) was obtained in 97.8% (n = 91) leading to an overall treatment-related morbidity of 2.2% (n = 2). There was no procedural mortality. CONCLUSION Our study shows that FD treatment of unruptured intracranial aneurysms is effective and safe with high occlusion rates and low rates of permanent morbidity at long-term follow-up.
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Affiliation(s)
- Andreas Simgen
- Department of Neuroradiology, Saarland University
Hospital, Homburg/Saar, Germany
| | - Christian Roth
- Department of Neuroradiology, Saarland University
Hospital, Homburg/Saar, Germany
| | - Johann Kulikovski
- Department of Neuroradiology, Saarland University
Hospital, Homburg/Saar, Germany
| | | | - Safwan Roumia
- Department of Neuroradiology, Saarland University
Hospital, Homburg/Saar, Germany
| | - Philipp Dietrich
- Department of Neuroradiology, Saarland University
Hospital, Homburg/Saar, Germany
| | | | - Michael Kettner
- Department of Neuroradiology, Saarland University
Hospital, Homburg/Saar, Germany
| | - Wolfgang Reith
- Department of Neuroradiology, Saarland University
Hospital, Homburg/Saar, Germany
| | - Umut Yilmaz
- Department of Neuroradiology, Saarland University
Hospital, Homburg/Saar, Germany
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19
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Teranishi K, Mishima Y, Taniguchi T, Fujii T, Nonaka S, Kitamura T, Kondo A, Oishi H. Preliminary Experience of the Surpass Streamline Flow Diverter for Large and Giant Unruptured Internal Carotid Artery Aneurysms. Neurol Med Chir (Tokyo) 2022; 62:451-457. [PMID: 36070961 PMCID: PMC9637403 DOI: 10.2176/jns-nmc.2022-0167] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
As of January 2021, the Surpass Streamline (SS) is the most recently approved flow diverter in Japan. A total of 28 Japanese patients, including 9 clinical trial patients, with 28 large or giant unruptured internal carotid artery (ICA) aneurysms, underwent SS embolization at Juntendo University Hospital. Procedural failure occurred in two patients due to the difficulty to navigate the device in the tortuous parent artery. Therefore, 26 patients with 26 aneurysms were available for clinical and anatomical assessments. Patients' mean age was 62.6 years (range 46-86), and 24 patients (92.3%) were female. Mean aneurysm size and neck width were 15.4 mm and 7.7 mm, respectively, with 20 saccular and 6 fusiform aneurysms. Seven aneurysms were symptomatic due to the aneurysmal mass effect. Twenty patients underwent a 6-month follow-up angiography to evaluate the degree of occlusion. Anatomical outcomes were 12 (60%) complete occlusion (CO), 4 (20%) residual neck (RN), and 4 (20%) residual aneurysm. Favorable aneurysm occlusion consisted of CO, and RN was achieved in 16 (80.0%). There were no significant device stenoses. Aneurysmal mass effect improved in one and was unchanged in eight patients. There were three device-related complications, namely, delayed aneurysm rupture, minor ischemic stroke, and device occlusion (11.5%). One patient with minor ischemic stroke fully recovered before 30 days, and our series showed 7.7% risk of major ipsilateral stroke and neurological death at 30 days. The SS embolization for large and giant unruptured ICA aneurysms offers satisfactory anatomical and clinical outcomes with a low risk of device-related complications.
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Affiliation(s)
- Kosuke Teranishi
- Department of Neurosurgery, Juntendo University, Faculty of Medicine
| | - Yumiko Mishima
- Department of Neurosurgery, Juntendo University, Faculty of Medicine
| | - Takahiko Taniguchi
- Department of Neuroendovascular Therapy, Juntendo University, Faculty of Medicine
| | - Takashi Fujii
- Department of Neuroendovascular Therapy, Juntendo University, Faculty of Medicine
| | - Senshu Nonaka
- Department of Neurosurgery, Juntendo University, Faculty of Medicine
| | - Takayuki Kitamura
- Department of Neurosurgery, Juntendo University, Faculty of Medicine.,Department of Neuroendovascular Therapy, Juntendo University, Faculty of Medicine
| | - Akihide Kondo
- Department of Neurosurgery, Juntendo University, Faculty of Medicine
| | - Hidenori Oishi
- Department of Neurosurgery, Juntendo University, Faculty of Medicine.,Department of Neuroendovascular Therapy, Juntendo University, Faculty of Medicine
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Yamasaki D, Fukuda H, Hamada F, Kida N, Fukui N, Okada K, Masahira N, Ohta T, Imamura H, Sakai N, Ueba T. Flow alteration therapy for impending rupture of intracranial giant aneurysm after flow diverter placement. Surg Neurol Int 2022; 13:323. [PMID: 36128122 PMCID: PMC9479598 DOI: 10.25259/sni_437_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Accepted: 07/14/2022] [Indexed: 11/18/2022] Open
Abstract
Background: Flow diverter (FD) placement is generally effective for intractable internal carotid artery (ICA) aneurysms. However, salvage treatment for the aneurysm enlarging even after FD placement remains to be elucidated. Additional overlapping FD placement is considered the first-line treatment for residual or recurrent aneurysms. However, it is unclear whether overlapping FD is also effective for enlarging giant aneurysms that are considered impending rupture status. Although parent artery occlusion is a promising option, treatment strategy must be optimized, especially when a critical perforating artery is involved. Case Description: A 74-year-old woman experienced rapid symptomatic growth of her giant supraclinoid ICA aneurysm 10 months after FD placement. We assumed that reinforcement of flow diverting effect alone would be less effective for this extremely intractable aneurysm with more aggressive clinical feature so that surgical bailout by parent artery occlusion was planned. Complete ICA obliteration underneath the aneurysm was unavailable due to the presence of anterior choroidal artery. Thus, we took a flow alteration strategy, where we created minimal retrograde flow through the parent artery by a combination of an extracranial-intracranial bypass and targeted endovascular proximal parent artery obliteration, resulting in prevention of aneurysmal rupture and further growth. Conclusion: Impending rupture of the intracranial giant aneurysm after FD placement may be controllable with a tailor-made parent artery occlusion strategy even when a critical perforating artery is involved.
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Affiliation(s)
- Daichi Yamasaki
- Department of Neurosurgery, Kochi University Hospital, Nankoku, Japan
| | - Hitoshi Fukuda
- Department of Neurosurgery, Kochi University Hospital, Nankoku, Japan
| | - Fumihiro Hamada
- Department of Neurosurgery, Kochi University Hospital, Nankoku, Japan
| | - Namito Kida
- Department of Neurosurgery, Kochi University Hospital, Nankoku, Japan
| | - Naoki Fukui
- Department of Neurosurgery, Kochi University Hospital, Nankoku, Japan
| | - Kenji Okada
- Department of Neurosurgery, Kochi University Hospital, Nankoku, Japan
| | - Noritaka Masahira
- Department of Neurosurgery, Kochi Health Sciences Center, Kochi, Japan
| | - Tsuyoshi Ohta
- Department of Neurosurgery, Kochi Health Sciences Center, Kochi, Japan
| | - Hirotoshi Imamura
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Hyogo, Japan
| | - Nobuyuki Sakai
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Hyogo, Japan
| | - Tetsuya Ueba
- Department of Neurosurgery, Kochi University Hospital, Nankoku, Japan
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21
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Li L, Gao BL, Shao QJ, Zhang GL, Wang ZL, Li TX, Zhu LF. Small Unruptured Intracranial Aneurysms Can Be Effectively Treated With Flow-Diverting Devices. Front Neurol 2022; 13:913653. [PMID: 35707031 PMCID: PMC9190436 DOI: 10.3389/fneur.2022.913653] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 04/29/2022] [Indexed: 11/13/2022] Open
Abstract
Purpose To investigate the effect and safety of flow diverters in the management of small (<10 mm in diameter) unruptured intracranial aneurysms. Materials and Methods One hundred and ten patients with 145 small intracranial aneurysms treated with flow diverters were retrospectively enrolled. The clinical, endovascular, and follow-up data were analyzed. Results One hundred twenty-one flow diverters were deployed for the treatment of 145 small intracranial aneurysms in 110 patients, and the stenting success rate was 99.1%. In 133 (91.7%) aneurysms, only flow-diverting devices were deployed, and in the rest 12 (8.3%) of aneurysms, coils were used to loosely pack the aneurysm after deployment of a flow-diverting device. Five patients (4.5%) experienced ischemic complications, but no hemorrhagic complications were occurred. All patients had clinical follow-up 6-18 (median 12) after the procedure, with the modified Rankin scale score (mRS) 0 in 101 patients, 1 in four patients, 2 in three patients, 4 in one patient, and 5 in one patient. Digital subtraction angiography was performed at follow-up in 90 (81.8%) patients with 118 (81.4%) aneurysms 6-18 months (median 12) after the procedure, with the Raymond grade I in 90 (76.2%) aneurysms and Raymond grade III in 28 (23.7%). Eighteen patients with 22 partially occluded aneurysms at the first angiographic follow-up experienced the second digital subtraction angiography 12-36 months (median 26) after the procedure, and 21 (95.5%) aneurysms were completely occluded. Two patients had asymptomatic in-stent stenosis. Conclusion Treatment of small unruptured intracranial aneurysms with flow diverters can be performed safely and effectively with satisfactory outcomes.
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Affiliation(s)
- Li Li
- Henan Provincial People's Hospital, Zhengzhou University, Zhengzhou, China
| | - Bu-Lang Gao
- Henan Provincial People's Hospital, Zhengzhou University, Zhengzhou, China
| | - Qiu-Ji Shao
- Henan Provincial People's Hospital, Zhengzhou University, Zhengzhou, China
| | - Guang-Lin Zhang
- Henan Provincial People's Hospital, Zhengzhou University, Zhengzhou, China
| | - Zi-Liang Wang
- Henan Provincial People's Hospital, Zhengzhou University, Zhengzhou, China
| | - Tian-Xiao Li
- Henan Provincial People's Hospital, Zhengzhou University, Zhengzhou, China
| | - Liang-Fu Zhu
- Henan Provincial People's Hospital, Zhengzhou University, Zhengzhou, China
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22
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Fan F, Fu Y, Liu J, Yang X, Zhang H, Li T, Shi H, Wan J, Zhao Y, Wang Y, Feng W, Song D, Wang Y, Mao G, Maimaitili A, Guan S. Multiple Pipeline Embolization Devices for the Treatment of Complex Intracranial Aneurysm: A Multi-Center Study. Front Aging Neurosci 2022; 14:905224. [PMID: 35769602 PMCID: PMC9234332 DOI: 10.3389/fnagi.2022.905224] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Accepted: 05/06/2022] [Indexed: 11/30/2022] Open
Abstract
Background The Pipeline for Uncoilable or Failed Aneurysms (PUFS) trial primarily demonstrated the safety and efficacy of the implantation of multiple pipeline embolization devices (multi-PEDs) for large/giant intracranial aneurysms. However, no study has focused on when, why, or how to apply multi-PEDs. Objective The purpose of this study was to investigate the indications and strategies of using multi-PEDs for complex intracranial aneurysms. Methods Patients who had been treated with two or more PEDs were included in the post-market multicenter registry study from 2014 to 2019, across 14 centers in China. Indications, strategies, perioperative safety, and clinical outcomes were retrospectively analyzed. The modified Rankin scale (mRS) score was used to evaluate clinical outcomes comprehensively, and the O’Kelly–Marotta (OKM) grading scale was used to evaluate aneurysm healing results. Results A total of 55 intracranial aneurysms were treated with multi-PEDs. There were 20 fusiform aneurysms with a large range, 25 large/giant saccular aneurysms, six aneurysms with failed treatment, and four aneurysms with greatly varied diameters of the parent artery. The strategies included telescope techniques in 40 patients and overlap techniques in 15 patients. In total, 120 stents were deployed in 55 patients. The operation styles included 25 patients (55.6%) with two PEDs, 21 patients (38.2%) with two PEDs combined with coiling, four patients (7.3%) with three PEDs, four patients (7.3%) with three PEDs combined with coiling, and one patient (1.8%) with four PEDs. Angiography revealed OKM D in two, OKM C in seven, and OKM A and B in 46 cases after surgery. During the perioperative period, eight patients developed neurological dysfunction, three of whom died. A total of thirty-four patients were followed up with digital subtraction angiography for 2–45 (8.2 ± 8.0) months. Angiography revealed OKM D in 26, OKM C in five, and OKM B in three. At the last follow-up, the mRS score was 0–1 in 52 patients. Conclusion The treatment of anterior circulation aneurysms with multi-PEDs is safe and effective. The implantation of multi-PEDs could be considered for large-scale fusiform aneurysms, large/giant saccular aneurysms with a jet-sign, salvage of failed PED treatments, and in cases where the diameter of the parent artery varies greatly.
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Affiliation(s)
- Feng Fan
- Department of Neurointervention Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yu Fu
- Department of Neurointervention Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Jianmin Liu
- Changhai Hospital Affiliated to Naval Medical University, Shanghai, China
| | - Xinjian Yang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Hongqi Zhang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Tianxiao Li
- Zhengzhou University People’s Hospital, Zhengzhou, China
| | - Huaizhang Shi
- First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Jieqing Wan
- Renji Hospital, School of Medical, Shanghai Jiao Tong University, Shanghai, China
| | - Yuanli Zhao
- Peking University International Hospital, Beijing, China
| | - Yunyan Wang
- Qilu Hospital of Shandong University, Jinan, China
| | - Wenfeng Feng
- Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Donglei Song
- Shanghai Donglei Brain Hospital, Shanghai, China
| | - Yang Wang
- First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Guohua Mao
- Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Aisha Maimaitili
- First Affiliated Hospital of Xinjiang Medical University, Ürümqi, China
| | - Sheng Guan
- Department of Neurointervention Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- *Correspondence: Sheng Guan,
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23
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Simgen A, Mayer C, Kettner M, Mühl-Benninghaus R, Reith W, Yilmaz U. Retrospective analysis of intracranial aneurysms after flow diverter treatment including color-coded imaging (syngo iFlow) as a predictor of aneurysm occlusion. Interv Neuroradiol 2022; 28:190-200. [PMID: 34107790 PMCID: PMC9131503 DOI: 10.1177/15910199211024056] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 05/16/2021] [Indexed: 01/13/2023] Open
Abstract
PURPOSE Flow Diverters (FD) have immensely extended the treatment of cerebral aneurysms in the past years. Complete aneurysm occlusion is a process that often takes a certain amount of time and is usually difficult to predict. Our aim was to investigate different syngo iFlow parameters in order to predict aneurysm occlusion. METHODS Between 2014 and 2018 patients with unruptured cerebral aneurysms treated with a FD were reviewed. Aneurysm occlusion and complication rates have been assessed.In addition, various quantitative criteria were assessed using syngo iFlow before, after the intervention, and after short and long-term digital subtraction angiography (DSA). RESULTS A total of 66 patients hosting 66 cerebral aneurysms were included in this study. 87.9% (n = 58) aneurysms in the anterior and 12.1% (n = 8) in the posterior circulation were treated. Adequate aneurysm occlusion at long-term follow-up (19.05 ± 15.1 months) was achieved in 90.9% (n = 60). Adequately occluded aneurysm revealed a significantly greater peak intensity delay (PI-D, p = 0.008) and intensity decrease ratio (ID-R, p < 0.001) compared to insufficiently occluded aneurysms. Increased intra-aneurysmal contrast agent intensity (>100%) after FD implantation resulted in an ID-R < 1, which was associated with aneurysm growth during follow-up DSA. Retreatment with another FD due to foreshortening and/or aneurysm growth was performed in 10.6% (n = 7). Overall morbidity and mortality rates were 1.5% (n = 1) and 0%. CONCLUSION The applied syngo iFlow parameters were found to be useful in predicting adequate aneurysm occlusion and foresee aneurysm growth, which might indicate the implantation of another FD.
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Affiliation(s)
- Andreas Simgen
- Departments of Neuroradiology, Saarland University
Hospital, Homburg/Saar, Germany
| | - Christine Mayer
- Departments of Neuroradiology, Saarland University
Hospital, Homburg/Saar, Germany
| | - Michael Kettner
- Departments of Neuroradiology, Saarland University
Hospital, Homburg/Saar, Germany
| | | | - Wolfgang Reith
- Departments of Neuroradiology, Saarland University
Hospital, Homburg/Saar, Germany
| | - Umut Yilmaz
- Departments of Neuroradiology, Saarland University
Hospital, Homburg/Saar, Germany
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Vertebral artery V3 portion-radial artery-distal common carotid artery (V3-RA-dCCA) bypass for large basilar trunk aneurysm with bilateral proximal common carotid artery occlusion-technical note. Acta Neurochir (Wien) 2022; 164:1031-1035. [PMID: 34273045 DOI: 10.1007/s00701-021-04930-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Accepted: 06/22/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Large basilar trunk aneurysm caused by bilateral occlusion of the proximal common carotid artery is rare. We treated one case with vertebral V3 portion-radial artery-distal common carotid artery (V3-RA-dCCA) bypass. CASE DESCRIPTION Basilar trunk aneurysm and bilateral occlusion of the proximal CCA were found incidentally in a 70-year-old woman. During the next 5 years, the aneurysm gradually enlarged to 12 mm, and blood flow of the anterior circulation was supplied through the posterior communicating artery. V3-RA-dCCA bypass was performed to reduce the stress of blood flow and prevent aneurysm growth and rupture. After exposing the neck portion, forearm of RA, and V3 portion of the vertebral artery, we created a space just below the sternocleidomastoid muscle to bypass the RA. We flushed the RA with albumin to stiffen the artery and temporarily clamped the bilateral sides of the RA to prevent twisting. We anastomosed the V3 and RA with a 9-0 thread and temporarily clamped the V3. After flushing the RA with albumin to prevent twisting, we clamped the external and internal carotid arteries, opened the dCCA with a vascular punch to prevent arterial dissection, and anastomosed the RA to the dCCA. The patency of the bypass was confirmed with Doppler and indocyanine green video angiography. The postoperative course was uneventful, bypass patency was good, and the aneurysm did not expand further. CONCLUSION V3-RA-dCCA bypass may be an effective and low-risk treatment for large basilar trunk aneurysms with bilateral occlusion of the proximal common carotid artery.
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25
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Choi JH, Sim SY, Shin YS, Chung J. A Single Flow Re-direction Endoluminal Device for the Treatment of Large and Giant Anterior Circulation Intracranial Aneurysms. Yonsei Med J 2022; 63:349-356. [PMID: 35352886 PMCID: PMC8965426 DOI: 10.3349/ymj.2022.63.4.349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 12/08/2021] [Accepted: 12/16/2021] [Indexed: 11/28/2022] Open
Abstract
PURPOSE The purpose of this study was to report the author's experiences in treating large (10-25 mm) and giant (>25 mm) intracranial aneurysms (IAs) using a single Flow Re-direction Endoluminal Device (FRED) without assistant coiling, with a focus on procedure-related complications. MATERIALS AND METHODS A total of 33 patients who were treated with FRED between January 2018 and July 2020 were retrospectively reviewed. The timing of procedure-related complications was chronologically categorized as acute (within 7 days), subacute (8 to 21 days), and delayed (after 21 days) periods. Follow-up angiography was performed at 2 to 27 months (mean 9.7 months), and clinical follow-up was performed at 1 to 31 months (mean 14.1 months) in all patients. RESULTS Six (18.2%) patients experienced procedure-related complications, including 2 (6.1%) in acute period, 1 (3.0%) in subacute period, and 3 (9.1%) in delayed period. Thromboembolic complications occurred in 5 (15.2%) patients and hemorrhagic complications in 1 (3.0%). Permanent morbidity and mortality rates were 3.0% each. Non-internal carotid artery (ICA) location of IAs (odds ratio 6.532; 95% confidence interval, 1.335-17.816; p=0.034) was the only independent risk factor for procedure-related complications on multivariate logistic regression analysis. CONCLUSION The procedure-related complication rate was 18.2% in this study. Procedure-related complications might increase when treating large and giant IAs located on a non-ICA, especially on the middle cerebral artery. Therefore, it may be suggested that neurointerventionists and endovascular neurosurgeons should pay attention to the location of IAs when treating large and giant IAs with a single FRED.
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Affiliation(s)
- Jai Ho Choi
- Department of Neurosurgery, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sook Young Sim
- Department of Neurosurgery, Ilsan Paik Hospital, College of Medicine, Inje University, Goyang, Korea
| | - Yong Sam Shin
- Department of Neurosurgery, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Joonho Chung
- Department of Neurosurgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.
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Yatomi K, Mitome-Mishima Y, Fujii T, Teranishi K, Oishi H, Kondo A. Outcomes following aneurysmal coil embolization with intentionally shortened low-profile visible intraluminal support stent deployment. Neuroradiol J 2022; 35:77-85. [PMID: 34187225 PMCID: PMC8826284 DOI: 10.1177/19714009211026925] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
PURPOSE Among all stents available for neuroendovascular therapy, the low-profile visible intraluminal support stent bears the highest metal coverage ratio. We deployed a low-profile visible intraluminal support stent with a delivery wire or/and microcatheter system push action to shorten the low-profile visible intraluminal support stent and thus achieve a flow diversion effect. We report our single-institution experience with the use of low-profile visible intraluminal support stents for intentionally shortened deployment (shortening group) and non-shortened deployment (non-shortening group) for unruptured intracranial aneurysms. METHODS We retrospectively reviewed the medical records of 130 patients with 131 intracranial aneurysms who were treated with low-profile visible intraluminal support stent-assisted coil embolization from February 2016-January 2019. All perioperative complications were noted. Every 6 months, we re-examined the patients with cerebral angiography or magnetic resonance angiography. The outcomes of aneurysm occlusion were evaluated by the modified Raymond-Roy occlusion classification. We used the finite element method and computational fluid dynamics to investigate the hemodynamics after shortened low-profile visible intraluminal support stent deployment. RESULTS Immediately after treatment, the modified Raymond-Roy occlusion classification was significantly better in the shortening group than in the non-shortening group (p<0.05). The latest angiographic outcomes showed the same tendency. Hemodynamic analysis by computational fluid dynamics suggested an adequate flow diversion effect with the use of our intentional shortening method. CONCLUSIONS Stent-assisted coil embolization using this technique showed good results of a high complete occlusion rate and low complication rate. These findings suggest that shortened low-profile visible intraluminal support stent deployment yields a flow diversion effect and may lead to early intra-aneurysmal thrombus formation.
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Affiliation(s)
- Kenji Yatomi
- Department of Neurosurgery, Juntendo
University Faculty of Medicine, Japan,Kenji Yatomi, Department of Neurosurgery, Juntendo
University Faculty of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-8421, Japan.
| | - Yumiko Mitome-Mishima
- Department of Neurosurgery, Juntendo
University Faculty of Medicine, Japan,Department of Neurosurgery, National
Defense Medical College, Japan
| | - Takashi Fujii
- Department of Neurosurgery, National
Defense Medical College, Japan,Department of Neuroendovascular Therapy,
Juntendo University Faculty of Medicine, Japan
| | - Kohsuke Teranishi
- Department of Neurosurgery, Juntendo
University Faculty of Medicine, Japan
| | - Hidenori Oishi
- Department of Neurosurgery, Juntendo
University Faculty of Medicine, Japan,Department of Neuroendovascular Therapy,
Juntendo University Faculty of Medicine, Japan
| | - Akihide Kondo
- Department of Neurosurgery, Juntendo
University Faculty of Medicine, Japan
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27
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Fujii T, Teranishi K, Yatomi K, Suzuki K, Mitome-Mishima Y, Kondo A, Oishi H. Long-term Follow-up Results after Flow Diverter Therapy Using the Pipeline Embolization Device for Large or Giant Unruptured Internal Carotid Artery Aneurysms: Single-center Retrospective Analysis in the Japanese Population. Neurol Med Chir (Tokyo) 2021; 62:19-27. [PMID: 34707069 PMCID: PMC8754679 DOI: 10.2176/nmc.oa.2021-0203] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Flow diverter (FD) therapy using Pipeline embolization device (PED) has become an important alternative to treat internal carotid artery (ICA) aneurysms. Herein, we report the long-term outcome for 3 years after FD therapy using PED for ICA aneurysms in Japan. The patients who underwent angiographical and/or clinical follow-up for 3 years after the FD therapy using PED of large or giant unruptured ICA aneurysms from December 2012 at our university hospital are the subjects of this study. We retrospectively reviewed the in- and outpatients’ medical charts, and written operative and radiological records. There were 84 patients with 90 aneurysms who could be clinically and/or angiographically followed up for 3 years. Of these, 7 aneurysms were only available for clinical follow-up. Of the remaining 83 aneurysms, 6 aneurysms had vessel occlusion due to stent thrombosis or parent artery occlusion, and 60 of the remaining 77 (77.9%) had complete occlusion. In multivariate analysis, older age (>70 years), wide neck, and non-adjunctive coiling contributed statistically significantly to incomplete occlusion. Of the 84 patients, 2 patients (2.4%) had delayed complications between 6 months and 3 years after the initial FD placement. Three patients (3.6%) had poor outcome due to postoperative major stroke complications, 2 of which were acute complications. The long-term results after FD therapy are good both angiographically and clinically. Endothelialization of the aneurysmal neck and intra-aneurysmal thrombosis contribute to complete occlusion. The primary reason for the somewhat low complete occlusion in Japan may be the patients are generally older.
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Affiliation(s)
- Takashi Fujii
- Department of Neuroendovascular Therapy, Juntendo University, Graduate School of Medicine
| | - Kohsuke Teranishi
- Department of Neurosurgery, Juntendo University, Graduate School of Medicine
| | - Kenji Yatomi
- Department of Neurosurgery, Juntendo University, Graduate School of Medicine
| | - Kazumoto Suzuki
- Department of Neurosurgery, Juntendo University, Graduate School of Medicine
| | | | - Akihide Kondo
- Department of Neurosurgery, Juntendo University, Graduate School of Medicine
| | - Hidenori Oishi
- Department of Neuroendovascular Therapy, Juntendo University, Graduate School of Medicine.,Department of Neurosurgery, Juntendo University, Graduate School of Medicine
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Prediction of atherosclerotic changes in cavernous carotid aneurysms based on computational fluid dynamics analysis: a proof-of-concept study. Neuroradiology 2021; 64:575-585. [PMID: 34505180 DOI: 10.1007/s00234-021-02803-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 09/01/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE Recent computational fluid dynamics (CFD) studies have demonstrated the concurrence of atherosclerotic changes in regions exposed to prolonged blood residence. In this proof-of-concept study, we investigated a small but homogeneous cohort of large, cavernous carotid aneurysms (CCAs) to establish the clinical feasibility of CFD analysis in treatment planning, based on the association between pathophysiology and hemodynamics. METHODS This study included 15 patients with individual large CCAs. We identified calcifications, which indicated atherosclerotic changes, using the masking data of digital subtraction angiography. We conducted a CFD simulation under patient-specific inlet flow rates measured using magnetic resonance (MR) velocimetry. In the post-CFD analysis, we calculated the blood residence time ([Formula: see text]) and segmented the surface exposed to blood residence time over 1 s ([Formula: see text]). We measured the decrease in volume after flow diversion using the original time-of-flight MR angiography data. RESULTS Calcifications were observed in the region with [Formula: see text]. In addition, the ratio of [Formula: see text] to the surface of the aneurysmal domain exhibited a negative relationship with the rate of volume reduction at the 6- and 12-month follow-ups. Post-CFD visualization demonstrated that intra-aneurysmal swirling flow prolonged blood residence time under the condition of a small inlet flow rate, when compared to the aneurysmal volume. CONCLUSION The results of this study suggest the usefulness of CFD analysis for the diagnosis of atherosclerotic changes in large CCAs that may affect the therapeutic response after flow diversion.
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29
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Kim S, Park KY, Chung J, Kim YB, Lee JW, Huh SK. Comparative Analysis of Feasibility of the Retrograde Suction Decompression Technique for Microsurgical Treatment of Large and Giant Internal Carotid Artery Aneurysms. J Korean Neurosurg Soc 2021; 64:740-750. [PMID: 34380192 PMCID: PMC8435642 DOI: 10.3340/jkns.2021.0066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 05/12/2021] [Indexed: 11/27/2022] Open
Abstract
Objective Retrograde suction decompression (RSD) is an adjuvant technique used for the microsurgical treatment of large and giant internal carotid artery (ICA) aneurysms. In this study, we analyzed the efficacy and safety of the RSD technique for the treatment of large and giant ICA aneurysms relative to other conventional microsurgical techniques.
Methods The aneurysms were classified into two groups depending on whether the RSD method was used (21 in the RSD group vs. 43 in the non-RSD group). Baseline characteristics, details of the surgical procedure, angiographic outcomes, clinical outcomes, and procedure-related complications of each group were reviewed retrospectively.
Results There was no significant difference in the rates of complete neck-clipping between the RSD (57.1%) and non-RSD (67.4%) groups. Similarly, there was no difference in the rates of good clinical outcomes (modified Rankin Scale score, 0–2) between the RSD (85.7%) and non-RSD (81.4%) groups. Considering the initial functional status, 19 of 21 (90.5%) patients in the RSD group and 35 of 43 (81.4%) patients in the non-RSD group showed an improvement or no change in functional status, which did not reach statistical significance.
Conclusion In this study, the microsurgical treatment of large and giant intracranial ICA aneurysms using the RSD technique obtained competitive angiographic and clinical outcomes without increasing the risk of procedure-related complications. The RSD technique might be a useful technical option for the microsurgical treatment of large and giant intracranial ICA aneurysms.
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Affiliation(s)
- Sunghan Kim
- Department of Neurosurgery, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea.,Department of Neurosurgery, Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Keun Young Park
- Department of Neurosurgery, Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Joonho Chung
- Department of Neurosurgery, Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Yong Bae Kim
- Department of Neurosurgery, Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Whan Lee
- Department of Neurosurgery, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Korea
| | - Seung Kon Huh
- Department of Neurosurgery, Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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Current Strategies in the Treatment of Intracranial Large and Giant Aneurysms. ACTA NEUROCHIRURGICA. SUPPLEMENT 2021. [PMID: 33973024 DOI: 10.1007/978-3-030-63453-7_3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2024]
Abstract
INTRODUCTION Very large and giant aneurysms are among the most challenging cerebrovascular pathologies in neurosurgery. METHODS The aim of this paper is to review the current literature on the management of very large and giant aneurysms and to describe representative cases illustrating possible treatment strategies. RESULTS In view of the poor natural history, active management using multiprofessional individualized approaches is required to achieve aneurysm occlusion, relief of mass effect, and obliteration of the embolic source. Both reconstructive (clipping, coiling, stent-assisted coiling, flow diversion [FD]) and deconstructive techniques (parent artery occlusion [PAO], PAO in conjunction with bypass surgery, and strategies of flow modification) are available to achieve definitive treatment with acceptable morbidity. CONCLUSIONS Patients harboring such lesions should be managed at high-volume cerebrovascular centers by multidisciplinary teams trained in all techniques of open and endovascular neurosurgery.
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Abbasi M, Savasatano LE, Brinjikji W, Kallmes KM, Mikoff N, Reierson N, Abdelmegeed M, Pederson J, Warren B, Touchette JC, Khan S, Kamrowski S, Barrett A, Kallmes DF, Kadirvel R. Endoluminal flow diverters in the treatment of sidewall and bifurcation aneurysm: A systematic review and meta-analysis of complications and angiographic outcomes. Interv Neuroradiol 2021; 28:229-239. [PMID: 34154429 DOI: 10.1177/15910199211026713] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND AND AIM The use of endoluminal flow diversion in bifurcation aneurysms has been questioned due to the potential for complications and lower occlusion rates. In this study we assessed outcomes of endovascular treatment of intracranial sidewall and bifurcation aneurysms with flow diverters. METHODS In July 2020, a literature search for all studies utilizing endoluminal flow diverter treatment for sidewall or bifurcation aneurysms was performed. Data were collected from studies that met our inclusion/exclusion criteria by two independent reviewers and confirmed by a third reviewer. Using random-effects meta-analysis the target outcomes including overall complications (hematoma, ischemic events, minor ischemic stroke, aneurysm rupture, side vessel occlusion, stenosis, thrombosis, transient ischemic stroke, and other complications), perioperative complications, and follow-up (long-term) aneurysm occlusion were intestigated. RESULTS Overall, we included 35 studies with 1084 patients with 1208 aneurysms. Of these aneurysms, 654 (54.14%) and 554 (45.86%) were classified as sidewall and bifurcation aneurysm, respectively, based on aneurysm location. Sidewall aneurysms had a similar total complication rate (R) of 27.12% (95% CI, 16.56%-41.09%), compared with bifurcation aneurysms (R, 20.40%, 95% CI, 13.24%-30.08%) (p = 0.3527). Follow-up angiographic outcome showed comparable complete occlusion rates for sidewall aneurysms (R 69.49%; 95%CI, 62.41%-75.75%) and bifurcation aneurysms (R 73.99%; 95% CI, 65.05%-81.31%; p = 0.4328). CONCLUSIONS This meta-analysis of sidewall and bifurcation aneurysms treated with endoluminal flow diverters demonstrated no significant differences in complications or occlusion rates. These data provide new information that can be used as a benchmark for comparison with emerging devices for the treatment of bifurcation aneurysms.
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Affiliation(s)
- Mehdi Abbasi
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Luis E Savasatano
- Department of Neurosurgery, 6915Mayo Clinic, Mayo Clinic, Rochester, MN, USA
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Bae HJ, Park YK, Cho DY, Choi JH, Kim BS, Shin YS. Predictors of the Effects of Flow Diversion in Very Large and Giant Aneurysms. AJNR Am J Neuroradiol 2021; 42:1099-1103. [PMID: 33926897 PMCID: PMC8191680 DOI: 10.3174/ajnr.a7085] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 12/24/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE The treatment paradigm for very large and giant aneurysms has recently changed to flow diversion, in light of the results of the Pipeline for Uncoilable or Failed Aneurysms trial. However, the effects of flow diversion were definitely unknown. We explored this topic and identified the predictors of such effects. MATERIALS AND METHODS We retrospectively reviewed 51 patients with unruptured aneurysms admitted to our institution for flow diversion between February 2014 and August 2019. Patients were categorized into an effect group (no filling or remnant entry) and a no-effect group (subtotal or total filling). We evaluated the aneurysm size and shape, incorporation vessel, parent artery stenosis and curvature, stagnation of contrast medium within the aneurysm, use of balloon angioplasty, and intra-aneurysm thrombus as potential predictors of the effects of flow diversion. RESULTS The effect group comprised 34 patients (66.7%, 34/51; no filling, 35.3%, 18/51; and remnant entry, 31.4%, 16/51). The no-effect group comprised 17 patients (33.3%, 17/51; subtotal filling, 29.4%, 15/51; and total filling, 3.9%, 2/51). An incorporation vessel and balloon angioplasty were independent risk factors for the no-effect group in multivariate logistic regression analyses (OR = 0.13 and 0.05; 95% confidence intervals, 0.02-0.62 and 0.00-0.32; P values, .021 and .004, respectively). CONCLUSIONS Flow diversion is effective for very large and giant aneurysms, but the outcomes require further improvement. The results of this study show that an incorporated vessel and excessive balloon angioplasty might compromise flow diversion. This finding can help improve the outcomes of flow diversion.
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Affiliation(s)
- H J Bae
- From the Department of Neurosurgery (H.J.B.), Yeouido St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Y K Park
- Department of Neurosurgery (Y.K.P.), Inje University Ilsan Paik Hospital, Goyang, Korea
| | - D Y Cho
- Department of Neurosurgery (D.Y.C.), Ewha Womans University, Seoul, Korea
| | - J H Choi
- Department of Neurosurgery (J.H.C., Y.S.S.), Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine. Seoul, Republic of Korea
| | - B S Kim
- Department of Radiology (B.S.K.), Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Y S Shin
- Department of Neurosurgery (J.H.C., Y.S.S.), Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine. Seoul, Republic of Korea
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Sugiyama N, Fujii T, Yatomi K, Teranishi K, Oishi H, Arai H. Endovascular Treatment for Lateral Wall Paraclinoid Aneurysms and the Influence of Internal Carotid Artery Angle. Neurol Med Chir (Tokyo) 2021; 61:275-283. [PMID: 33716235 PMCID: PMC8048120 DOI: 10.2176/nmc.oa.2020-0307] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Lateral wall paraclinoid aneurysms (LPA) are a rare type of aneurysm located on the lesser curve side of the internal carotid artery (ICA) bend, at the level of the anterior clinoid process. The objective of this study was to assess the influence of flexion of the ICA on the morphology of aneurysms and outcome of endovascular treatment. Between 2003 and 2018, we treated 643 cases of unruptured paraclinoid aneurysms with endovascular therapy in our institution. Of those cases, aneurysms projecting laterally on preoperative angiography were defined as LPA. The degree of bending of the ICA (ICA angle) was measured and statistically analyzed in relation to the aneurysm characteristics and the occlusion status after treatment. In all, 43 aneurysms were identified. ICA angle was positively correlated with the maximum dome size of the aneurysm (P <0.01) and the aspect ratio (P <0.01), and negatively correlated with the volume coil embolization ratio (P <0.01). Complete occlusion (CO) was achieved in 23 cases (53.5%) immediately after treatment, and in 35 cases (81.4%) at follow-up. The mean ICA angle in the incomplete occlusion group was significantly larger than in the CO group (P = 0.01). Larger ICA angle resulted in recurrence, whereas smaller ICA angle was more likely to obtain progressive thrombosis (P = 0.02). Endovascular treatment for LPA was safe and effective. The degree of flexion of the ICA may contribute to the level of hemodynamic stress on the aneurysm, its morphology, and the embolization effect.
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Affiliation(s)
- Natsuki Sugiyama
- Department of Neurosurgery, Juntendo University Faculty of Medicine
| | - Takashi Fujii
- Department of Neuroendovascular Therapy, Juntendo University Faculty of Medicine
| | - Kenji Yatomi
- Department of Neurosurgery, Juntendo University Faculty of Medicine
| | - Kosuke Teranishi
- Department of Neurosurgery, Juntendo University Faculty of Medicine
| | - Hidenori Oishi
- Department of Neurosurgery, Juntendo University Faculty of Medicine.,Department of Neuroendovascular Therapy, Juntendo University Faculty of Medicine
| | - Hajime Arai
- Department of Neurosurgery, Juntendo University Faculty of Medicine
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Fujii T, Oishi H, Teranishi K, Yatomi K, Suzuki K. Flow diverter device placement for cerebral aneurysm is not effective for the patient with parent artery occlusion for contralateral aneurysm. Neuroradiol J 2020; 33:465-470. [PMID: 33283673 DOI: 10.1177/1971400920964715] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE There have been many reports on the risks of enlargement and rupture of residual aneurysms and de novo aneurysm formation in the contralateral internal carotid artery after parent artery occlusion (PAO). In the present study, we investigated the efficacy of flow diverter device placement (FDDP) for the treatment of contralateral internal carotid artery aneurysms after PAO. METHODS After 11 patients, who had bilateral large or giant internal carotid aneurysms, were treated for either side with PAO or FDDP, they underwent FDDP for residual lesions in our hospital between October 2015 and June 2018. The patients were divided into two groups, depending on the prior procedure: PAO or FDDP. The embolic state after subsequent FDDP was evaluated by angiography. The embolic state was graded using the O'Kelly Marotta scale. Patients' characteristics and the embolic state of intracranial aneurysms after FDDP were compared between the two groups. RESULTS Comparing patients' characteristics between the PAO group and FDDP group, statistically significant differences were observed in laterality of the lesions and the interval between prior treatment and FDDP for residual aneurysms (p < 0.05). The embolic state at the one-year follow-up revealed that there could be significantly sufficient embolisation in the FDDP group (p < 0.05). CONCLUSION When FDDP is performed for the contralateral lesion after PAO treatment, it is difficult to attain sufficient embolisation of intracranial aneurysms because haemodynamic load in this procedure is large compared to that in a regular FDDP.
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Affiliation(s)
- Takashi Fujii
- Department of Neuroendovascular Therapy, Juntendo University, Faculty of Medicine, Japan
| | - Hidenori Oishi
- Department of Neuroendovascular Therapy, Juntendo University, Faculty of Medicine, Japan.,Department of Neurosurgery, Juntendo University, Faculty of Medicine, Japan
| | - Kohsuke Teranishi
- Department of Neurosurgery, Juntendo University, Faculty of Medicine, Japan
| | - Kenji Yatomi
- Department of Neurosurgery, Juntendo University, Faculty of Medicine, Japan
| | - Kazumoto Suzuki
- Department of Neurosurgery, Juntendo University, Faculty of Medicine, Japan
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Hou K, Li G, Lv X, Xu B, Xu K, Yu J. Delayed rupture of intracranial aneurysms after placement of intra-luminal flow diverter. Neuroradiol J 2020; 33:451-464. [PMID: 32851918 PMCID: PMC7788679 DOI: 10.1177/1971400920953299] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Though flow diverter is a safe and efficient modality, some patients can experience delayed aneurysmal rupture. The mechanism of delayed rupture is still obscure to us. METHODS We performed a systematic search in the PubMed database for patients with delayed rupture of intracranial aneurysms after flow diverter placement. RESULTS A total of 36 articles reporting on 60 patients were included in the final analysis. Of the 49 patients with description of presenting symptoms, six (12.2%) patients were incidentally diagnosed, 39 (87.8%) patients were admitted for aneurysmal rupture or mass effect. Multiple flow diverters were used in 38.3% (18/47) of the patients. Coil assistance was applied in 13.0% (7/54) of the patients. Delayed aneurysmal rupture led to intracranial hemorrhage or carotid-cavernous sinus fistula (CCF) in 76.8% (43/56) and 23.2% (13/56) of the patients, respectively. Of the 55 patients with description of outcome, 14 (25.5%) patients achieved good recovery, one (1.8%) patient was severely disabled, 40 (72.7%) patients died. All of the patients in the CCF group survived and experienced good recovery. CONCLUSION Increased intra-aneurysmal pressure, destabilization of the aneurysm wall by intra-aneurysmal thrombus, persistent residual intra-aneurysmal flow, characteristics of the specific aneurysm, and mechanical injury by the flow diverter might conjointly contribute to the final delayed rupture. There has been no established preventive measure to decrease the incidence of delayed rupture yet. The treatment and outcome depend on the presentation of delayed rupture. Patients presenting with aneurysm-related intracranial hemorrhage have a dismal outcome. Those presenting with CCFs usually have a satisfactory recovery.
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Affiliation(s)
- Kun Hou
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, China
| | - Guichen Li
- Department of Neurology, The First Hospital of Jilin University, Changchun, China
| | - Xianli Lv
- Department of Neurosurgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Baofeng Xu
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, China
| | - Kan Xu
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, China
| | - Jinlu Yu
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, China
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Choi JH, Lee KS, Kim BS, Shin YS. Treatment outcomes of large and giant intracranial aneurysms according to various treatment modalities. Acta Neurochir (Wien) 2020; 162:2745-2752. [PMID: 32827268 DOI: 10.1007/s00701-020-04540-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 08/16/2020] [Indexed: 12/18/2022]
Abstract
PURPOSE This study aimed to compare the treatment outcomes of large (15-25 mm) and giant (> 25 mm) intracranial aneurysms (IAs), according to different treatment modalities. METHODS In total, 112 patients with large and giant IAs treated with various treatment modalities between January 2009 and December 2018 were retrospectively reviewed. Clinical and radiological parameters were analyzed and correlated with the treatment modality. RESULTS A total of 141 procedures were performed on 112 patients. We initially treated 47 cases with coil embolization, 39 with flow diverter (FD), 13 with direct clipping, and 13 with parent artery occlusion (PAO). Recurrence (46.8%) and retreatment (31.9%) rates were significantly higher in the coiling group (p < 0.001). Complete occlusion rate (36.3%) was significantly lower in the coiling group (p = 0.027). PAO could achieve a high complete occlusion rate (90.9%) with low complication rate (12.5%). The total complication rate was 17%. In the multivariate logistic regression analysis, FD (OR 3.406, p = 0.036) and direct clipping (OR 5.732, p = 0.017) showed a significantly higher complication rate than coiling. The overall mortality rate was 8% (8/139 procedures). At the last follow-up (mean 30.6 ± 26.4 months), 70 of 96 patients (72.9%) showed complete or near-complete occlusion. Good functional outcome (mRS ≤ 2) was observed in 90 of 112 (80.3%) patients at the last follow-up (mean 33.2 ± 30.5 months). CONCLUSIONS Good clinical and radiologic outcomes with acceptable complication and mortality rates can be achieved by various treatment modalities. The selection of appropriate modality should be individualized based on the angiographic findings and clinical symptoms.
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Affiliation(s)
- Jai Ho Choi
- Department of Neurosurgery, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpodaero, Seochogu,, Seoul, Korea
| | - Kwan Sung Lee
- Department of Neurosurgery, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpodaero, Seochogu,, Seoul, Korea
| | - Bum-Soo Kim
- Department of Radiology, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpodaero, Seochogu, Seoul, Korea
| | - Yong Sam Shin
- Department of Neurosurgery, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpodaero, Seochogu,, Seoul, Korea.
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Fujii T, Oishi H, Teranishi K, Yatomi K, Suzuki K, Arai H. Outcome of flow diverter placement for intracranial aneurysm with dual antiplatelet therapy and oral anticoagulant therapy. Interv Neuroradiol 2020; 26:532-538. [PMID: 32727310 PMCID: PMC7645175 DOI: 10.1177/1591019920947878] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 07/14/2020] [Indexed: 10/24/2023] Open
Abstract
PURPOSE Antiplatelet therapy initiated before flow diverter placement is effective for the prevention of ischemic complications. However, the effectiveness of oral anticoagulant treatment is unclear. This retrospective study evaluated the complications and obliteration rates after flow diverter placement in patients taking anticoagulants. METHODS A total of 155 cases were treated by Pipeline Flex placement for unruptured large and giant cerebral aneurysms in our hospital between October 2015 and June 2019. The groups of 8 patients taking anticoagulants before operation and 147 patients not taking anticoagulants were compared. RESULTS Clopidogrel oral dose (P = 0.002) was significantly lower in the anticoagulant group. Delayed aneurysm rupture (P = 0.002) and additional treatment (P = 0.009) rates were significantly higher and complete obliteration rate (P = 0.011) was lower in the anticoagulant group. CONCLUSIONS Additional oral anticoagulant administration before flow diverter placement does not reduce ischemic complications compared to dual antiplatelet therapy, but does increase hemorrhagic complications, especially delayed aneurysm rupture. Complete obliteration of the cerebral aneurysm is difficult to achieve in patients taking anticoagulants.
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Affiliation(s)
- Takashi Fujii
- Department of Neuroendovascular Therapy, Faculty of Medicine, Juntendo University, Tokyo, Japan
| | - Hidenori Oishi
- Department of Neuroendovascular Therapy, Faculty of Medicine, Juntendo University, Tokyo, Japan
- Department of Neurosurgery, Faculty of Medicine, Juntendo University, Tokyo, Japan
| | - Kohsuke Teranishi
- Department of Neurosurgery, Faculty of Medicine, Juntendo University, Tokyo, Japan
| | - Kenji Yatomi
- Department of Neurosurgery, Faculty of Medicine, Juntendo University, Tokyo, Japan
| | - Kazumoto Suzuki
- Department of Neurosurgery, Faculty of Medicine, Juntendo University, Tokyo, Japan
| | - Hajime Arai
- Department of Neurosurgery, Faculty of Medicine, Juntendo University, Tokyo, Japan
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Luzzi S, Gragnaniello C, Giotta Lucifero A, Del Maestro M, Galzio R. Surgical Management of Giant Intracranial Aneurysms: Overall Results of a Large Series. World Neurosurg 2020; 144:e119-e137. [PMID: 32949801 DOI: 10.1016/j.wneu.2020.08.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Revised: 07/30/2020] [Accepted: 08/01/2020] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To review and discuss surgical treatment options for giant intracranial aneurysms (GIAs), focusing on indications, technical aspects, and results, along with some illustrative cases. METHODS We reviewed the data of 82 consecutive patients surgically managed between January 2000 and December 2019 for treatment of a GIA. RESULTS Male sex and hemorrhage at presentation were prevalent. The average follow-up was 81.2 ± 45 months. The anterior circulation was involved in 76.8% of GIAs. If the GIA showed a clear neck, minimal atherosclerosis, or intrasaccular thrombosis, and ≤2 branches arising from the neck, it was reconstructed. This procedure was possible in 78% of cases. The technique also involved temporary clipping, remodeling, and thrombectomy, as well as fragmentation techniques. Angioarchitectural features other than these techniques underwent bypass and aneurysm trapping. Most bypasses were extracranial to intracranial and high flow. Flow capacity, collateral circulation, and availability of the donor vessel mainly affected the choice of the type of bypass. Overall, successful exclusion of the GIA was 91.4%. The need for retreatment and complication rate were 3.6% and 19.5%, respectively. A good overall outcome (modified Rankin Scale score 0-3) was achieved in 84.2% of patients, and mortality was 10%. CONCLUSIONS Microneurosurgical techniques still maintain a significant role for most GIAs, with a high durability and acceptable rate of morbidity and mortality. Clip reconstruction is the first-line surgical treatment option, whereas bypass is indicated in cases of planned or unplanned sacrifice of the parent artery to prevent long-term ischemic complications.
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Affiliation(s)
- Sabino Luzzi
- Neurosurgery Unit, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy; Neurosurgery Unit, Department of Surgical Sciences, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.
| | - Cristian Gragnaniello
- Department of Neurological Surgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Alice Giotta Lucifero
- Neurosurgery Unit, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Mattia Del Maestro
- Neurosurgery Unit, Department of Surgical Sciences, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy; PhD School in Experimental Medicine, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Renato Galzio
- Neurosurgery Unit, Maria Cecilia Hospital, Cotignola, Italy
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Kawauchi S, Chida K, Moritake T, Hamada Y, Matsumaru Y, Tsuruta W, Sato M, Hosoo H, Sun L. TREATMENT OF INTERNAL CAROTID ANEURYSMS USING PIPELINE EMBOLIZATION DEVICES: MEASURING THE RADIATION DOSE OF THE PATIENT AND DETERMINING THE FACTORS AFFECTING IT. RADIATION PROTECTION DOSIMETRY 2020; 188:389-396. [PMID: 31922569 DOI: 10.1093/rpd/ncz298] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Revised: 09/28/2019] [Accepted: 12/15/2019] [Indexed: 06/10/2023]
Abstract
The purpose of this study was to measure the peak skin dose (PSD) and bilateral lens doses using radiophotoluminescence glass dosimeters and to determine the factors influencing the radiation dose in cases of cerebral aneurysm treated with pipeline embolization devices (PEDs). The cumulative dose, PSD and right and left lens doses were 3818.1 ± 1604.6, 1880.0 ± 723.0, 124.8 ± 49.2 and 180.7 ± 124.8 mGy, respectively. Using multivariate analysis, body mass index (p < 0.01; odds ratio (OR) = 1.806; 95% confidence interval (CI) = 1.007-3.238) and deployment time of PED (p < 0.05; OR = 1.107; 95% CI = 1.001-1.224) were found to be the independent predictors of PSD exceeding 2 Gy. Measures such as collimation of the radiation field and optimization of radiation dose should be taken to reduce the radiation to the patient.
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Affiliation(s)
- Satoru Kawauchi
- Department of Radiology, Toranomon Hospital, 2-2-2 Toranomon, Minato-ku, Tokyo 105-8470, Japan
- Course of Radiological Technology, Health Sciences, Tohoku University Graduate School of Medicine, 2-1 Seiryo, Aoba-ku, Sendai, Miyagi 980-8575, Japan
- Okinaka Memorial Institute for Medical Research, 2-2-2 Toranomon, Minato-ku, Tokyo 105-8470, Japan
| | - Koichi Chida
- Course of Radiological Technology, Health Sciences, Tohoku University Graduate School of Medicine, 2-1 Seiryo, Aoba-ku, Sendai, Miyagi 980-8575, Japan
| | - Takashi Moritake
- Department of Radiological Health Science, Institute of Industrial Ecological Sciences, University of Occupational and Environmental Health, Japan, 1-1, Iseigaoka, Yahatanishi-ku, Kitakyushu, Fukuoka 807-8555, Japan
| | - Yusuke Hamada
- Department of Radiology, Toranomon Hospital, 2-2-2 Toranomon, Minato-ku, Tokyo 105-8470, Japan
| | - Yuji Matsumaru
- Division for Stroke Prevention and Treatment, Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki 305-8575, Japan
| | - Wataro Tsuruta
- Department of Endovascular Neurosurgery, Toranomon Hospital, 2-2-2 Toranomon, Minato-ku, Tokyo 105-8470, Japan
| | - Masayuki Sato
- Division for Stroke Prevention and Treatment, Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki 305-8575, Japan
| | - Hisayuki Hosoo
- Department of Endovascular Neurosurgery, Toranomon Hospital, 2-2-2 Toranomon, Minato-ku, Tokyo 105-8470, Japan
| | - Lue Sun
- Health Research Institute, Department of Life Science and Biotechnology, National Institute of Advanced Industrial Science and Technology (AIST), Central 6, 1-1-1 Higashi, Tsukuba, Ibaraki 305-8566, Japan
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A Case of Delayed Intraparenchymal Hemorrhage Due to Hyperperfusion After Flow Diverter Treatment. J Stroke Cerebrovasc Dis 2020; 29:104869. [PMID: 32417244 DOI: 10.1016/j.jstrokecerebrovasdis.2020.104869] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Accepted: 04/05/2020] [Indexed: 11/20/2022] Open
Abstract
Delayed intraparenchymal hemorrhage (DIPH) is one of the complications of flow diverter (FD) treatment, however, the mechanism is unclear. We present the case of a 54-year-old woman with a partially thrombosed large internal carotid artery aneurysm. She presented intraparenchymal hemorrhage in the right parietal lobe three days after the successful FD treatment. We performed endoscopic hematoma removal, and then her consciousness disturbance was fully recovered. IMP single-photon emission computed tomography showed significant increase of cerebral blood flow in the right hemisphere. We diagnosed DIPH associated with hyperperfusion after FD treatment. It is necessary to consider that DIPH due to hyperperfusion may occur after FD treatment.
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Park KY, Yeon JY, Kim BM, Jeon P, Kim JH, Jang CK, Kim DJ, Lee JW, Kim YB, Chung J, Song DH, Park HG, Park JS. Efficacy and Safety of Flow-Diverter Therapy for Recurrent Aneurysms after Stent-Assisted Coiling. AJNR Am J Neuroradiol 2020; 41:663-668. [PMID: 32165365 DOI: 10.3174/ajnr.a6476] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Accepted: 01/27/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND PURPOSE Flow-diverter treatment for previously stented aneurysms has been reported to be less effective and prone to complications. In this study, we evaluated the effectiveness and safety of flow diverters for recurrent aneurysms after stent-assisted coiling. MATERIALS AND METHODS Patients who underwent flow-diverter placement for recurrent aneurysms after stent-assisted coiling between March 2015 and March 2019 were recruited. Clinical and radiographic characteristics and clinical and angiographic outcomes were retrospectively evaluated. RESULTS Among 133 patients who underwent flow-diverter insertion, 17 (male/female ratio = 5:12; mean age, 53.8 years) were treated for recurrent aneurysms after stent placement with (n = 16) or without (n = 1) coiling. Eight patients initially presented with subarachnoid hemorrhage; 7, with headache; and 2, with visual field defects. Angiographic morphology included large/giant saccular in 12 patients, dissecting in 2, fusiform in 1, traumatic pseudoaneurysm in 1, and ruptured blood blister-like aneurysm in 1. The duration between the first treatment and flow-diverter placement ranged from 2 weeks to 15 months (median, 6 months). Flow-diverter placement was successful in all cases without any complications. All patients had favorable outcomes (mRS, 0-2), without any newly appearing symptoms. Aneurysms were followed up with conventional angiography at least once in 6-18 months. Sixteen aneurysms showed complete occlusion, and 1 aneurysm was enlarged. CONCLUSIONS Results from this case series investigating flow-diverter placement for recurrent aneurysms after stent-assisted coiling suggested that the procedure is safe and effective. Further study in a larger population may be warranted.
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Affiliation(s)
- K Y Park
- From the Department of Neurosurgery (K.Y.P., C.K.J., J.W.L., Y.B.K., J.C.), Yonsei University College of Medicine, Seoul, Republic of Korea
| | - J Y Yeon
- Department of Neurosurgery (J.Y.Y.), Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - B M Kim
- Department of Radiology (B.M.K., J.-H.K., D.J.K., D.H.S., H.G.P., J.S.P.), Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - P Jeon
- Department of Radiology (P.J.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - J-H Kim
- Department of Radiology (B.M.K., J.-H.K., D.J.K., D.H.S., H.G.P., J.S.P.), Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - C K Jang
- From the Department of Neurosurgery (K.Y.P., C.K.J., J.W.L., Y.B.K., J.C.), Yonsei University College of Medicine, Seoul, Republic of Korea
| | - D J Kim
- Department of Radiology (B.M.K., J.-H.K., D.J.K., D.H.S., H.G.P., J.S.P.), Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - J W Lee
- From the Department of Neurosurgery (K.Y.P., C.K.J., J.W.L., Y.B.K., J.C.), Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Y B Kim
- From the Department of Neurosurgery (K.Y.P., C.K.J., J.W.L., Y.B.K., J.C.), Yonsei University College of Medicine, Seoul, Republic of Korea
| | - J Chung
- From the Department of Neurosurgery (K.Y.P., C.K.J., J.W.L., Y.B.K., J.C.), Yonsei University College of Medicine, Seoul, Republic of Korea
| | - D H Song
- Department of Radiology (B.M.K., J.-H.K., D.J.K., D.H.S., H.G.P., J.S.P.), Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - H G Park
- Department of Radiology (B.M.K., J.-H.K., D.J.K., D.H.S., H.G.P., J.S.P.), Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - J S Park
- Department of Radiology (B.M.K., J.-H.K., D.J.K., D.H.S., H.G.P., J.S.P.), Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
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OĞUZ Ş, TABAKCI ÖN, UYSAL E, BULUT E, DİNÇ H. Pipeline Flex Embolization Device (PED Flex) for the treatment of intracranial
aneurysms: Periprocedural outcomes and first-year angiographic results. Turk J Med Sci 2019; 49:1640-1646. [PMID: 31655536 PMCID: PMC7518671 DOI: 10.3906/sag-1906-116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 09/18/2019] [Indexed: 11/03/2022] Open
Abstract
Background/aim The Pipeline Flex Embolization Device (PED Flex) is a new updated version of the PED classic that incorporates a new delivery system to allow facilitation of stent deployment, resheathing, and removal of the capture coil. This study evaluated the PED Flex in terms of the technical aspects of the procedure and first-year follow-up results. Materials and methods This retrospective study involved prospectively collected data from May 2015 to August 2017. The primary endpoint was technical aspects of the procedure, and the secondary endpoint was first-year follow-up results. Results Forty-nine patients with 59 target intracranial aneurysms were enrolled. Patients’ mean age was 52 years (range 21−71 years), and 31 (63.0%) were female. All aneurysms except for three were unruptured. The mean aneurysm diameter was 8 mm. Forty-seven patients with 56 aneurysms were successfully treated. Due to advancement, repositioning, and migration problems, 8 (13.1%) stents were not deployed and discharged. The total aneurysm occlusion rate was 77.0%. The mortality rate was 4.3%. Conclusion Our experience shows that the applicability and safety of the renewed delivery system provided by PED Flex for improving device apposition and opening has been proven with one-year angiographic and clinical follow-up results.
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Affiliation(s)
- Şükrü OĞUZ
- Department of Radiology, Faculty of Medicine, Karadeniz Technical University, TrabzonTurkey
| | - Ömer Naci TABAKCI
- Department of Radiology, Şişli Hamidiye Etfal Training and Research Hospital, İstanbulTurkey
| | - Ender UYSAL
- Department of Radiology, Şişli Hamidiye Etfal Training and Research Hospital, İstanbulTurkey
| | - Eser BULUT
- Department of Radiology, Kanuni Training and Research Hospital, TrabzonTurkey
| | - Hasan DİNÇ
- Department of Radiology, Faculty of Medicine, Karadeniz Technical University, TrabzonTurkey
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A Retrospective Analysis of Treatment Outcomes of 40 Incidental Cavernous Carotid Aneurysms. World Neurosurg 2019; 130:e1034-e1040. [DOI: 10.1016/j.wneu.2019.07.071] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 07/04/2019] [Accepted: 07/05/2019] [Indexed: 11/22/2022]
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Abe Y, Yuki I, Otani K, Shoji T, Ishibashi T, Murayama Y. Agreement of intracranial vessel diameters measured on 2D and 3D digital subtraction angiography using an automatic windowing algorithm. J Neuroradiol 2019; 48:311-315. [PMID: 31563590 DOI: 10.1016/j.neurad.2019.08.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 08/16/2019] [Accepted: 08/19/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND PURPOSE Precise vessel measurement plays a major role in size selection of stents used for the treatment of intracranial aneurysms and became even more critical after the introduction of flow diverter stents. We assessed agreement between intracranial vessel diameters of aneurysm patients measured on 2D digital subtraction (2D DSA) and 3D volume rendering digital subtraction angiography (3D DSA) images using an automatic windowing algorithm. MATERIALS AND METHODS Ten patients with intracranial aneurysms were enrolled and 120 measurement points were selected on both 2D and 3D DSA images acquired by a biplane angiographic system. Automatic windowing was applied to the 3D DSA images. Inter-method agreement of vessel measurements on 2D and 3D DSA images was assessed by Bland Altman plots and intraclass correlation coefficients (ICC). Inter- and intra-rater agreement of measurements on 3D DSA images were assessed by ICCs. RESULTS The mean differences between measurements on 2D and 3D DSA images were 0.14mm for the ICA, and 0.18mm for the ACA and MCA, which is about the size of one 3D DSA image voxel. For ICA measurements, inter-method, inter-rater and intra-rater agreements were good or excellent (consistency and absolute ICC≥0.95). For ACA and MCA measurements, the inter-method, inter-rater and intra-rater agreements were also good or excellent (consistency ICC=0.94, 0.89 and 0.93, absolute ICC=0.83, 0.84 and 0.85 respectively). CONCLUSIONS Vessel diameters may be measured on 3D DSA images with sufficient reliability for clinical use when applying an automatic windowing algorithm.
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Affiliation(s)
- Y Abe
- Department of Radiology, The Jikei University Hospital, Tokyo, Japan.
| | - I Yuki
- Department of Neurosurgery, The Jikei University School of Medicine, Tokyo, Japan
| | - K Otani
- Siemens Healthcare, Tokyo, Japan
| | - T Shoji
- Department of Radiology, The Jikei University Hospital, Tokyo, Japan
| | - T Ishibashi
- Department of Neurosurgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Y Murayama
- Department of Neurosurgery, The Jikei University School of Medicine, Tokyo, Japan
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Kikkawa Y, Kayahara T, Teranishi A, Shibata A, Suzuki K, Kamide T, Ikeda T, Kurita H. Predictors of the Resolution of Cavernous Sinus Syndrome Caused by Large/Giant Cavernous Carotid Aneurysms After Parent Artery Occlusion with High-Flow Bypass. World Neurosurg 2019; 132:e637-e644. [PMID: 31442640 DOI: 10.1016/j.wneu.2019.08.059] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 08/08/2019] [Accepted: 08/09/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To evaluate the clinical results and factors related to the resolution of preoperative cranial neuropathy after internal carotid artery ligation with high-flow bypass in patients with symptomatic large or giant cavernous carotid aneurysms. METHODS This study included 18 consecutive patients (15 women) with cranial neuropathy. All patients underwent therapeutic internal carotid artery ligation with high-flow bypass using a radial artery graft. Patient demographics, duration of symptoms, clinical outcomes, complications, and radiographic findings were retrospectively analyzed. The mean follow-up period was 31.0 months (range: 3-74 months). RESULTS Patients' mean age was 66.6 years, and the mean aneurysm size was 23.7 mm. Six patients (33%) had partially thrombosed aneurysms. Preoperatively, 16 (89%) and 8 (44%) patients presented with ophthalmoplegia and facial pain, respectively. Bypass patency was confirmed in 15 patients (83%), and obliteration of the aneurysm was confirmed in all patients at the final follow-up. Preoperative ophthalmoplegia resolved in 10 patients (63%), and trigeminal pain resolved in all patients. Postoperative resolution of patients' ophthalmoplegia was significantly associated with age (P = 0.044), symptom duration before treatment (P = 0.042), and the degree of ophthalmoplegia (P = 0.046). The degree of postoperative residual ophthalmoplegia was positively correlated with the duration of ophthalmoplegia from onset to surgery (r = 0.619; P = 0.011). Preoperative trigeminal pain resolved regardless of the preoperative duration of this symptom in all patients. CONCLUSIONS Early treatment is recommended when treating large or giant cavernous carotid aneurysms with cranial neuropathy. Complete resolution is possible in younger patients with partial neuropathy.
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Affiliation(s)
- Yuichiro Kikkawa
- Department of Cerebrovascular Surgery, Saitama Medical University International Medical Center, Saitama, Japan; Department of Neurosurgery, Saitama Prefecture Cardiovascular and Respiratory Center, Saitama, Japan.
| | - Tomomichi Kayahara
- Department of Cerebrovascular Surgery, Saitama Medical University International Medical Center, Saitama, Japan
| | - Akio Teranishi
- Department of Cerebrovascular Surgery, Saitama Medical University International Medical Center, Saitama, Japan
| | - Aoto Shibata
- Department of Cerebrovascular Surgery, Saitama Medical University International Medical Center, Saitama, Japan; Department of Neurosurgery, Saitama Prefecture Cardiovascular and Respiratory Center, Saitama, Japan
| | - Kaima Suzuki
- Department of Cerebrovascular Surgery, Saitama Medical University International Medical Center, Saitama, Japan
| | - Tomoya Kamide
- Department of Cerebrovascular Surgery, Saitama Medical University International Medical Center, Saitama, Japan
| | - Toshiki Ikeda
- Department of Cerebrovascular Surgery, Saitama Medical University International Medical Center, Saitama, Japan
| | - Hiroki Kurita
- Department of Cerebrovascular Surgery, Saitama Medical University International Medical Center, Saitama, Japan
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Bhatia KD, Kortman H, Orru E, Klostranec JM, Pereira VM, Krings T. Periprocedural complications of second-generation flow diverter treatment using Pipeline Flex for unruptured intracranial aneurysms: a systematic review and meta-analysis. J Neurointerv Surg 2019; 11:817-824. [DOI: 10.1136/neurintsurg-2019-014937] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 04/30/2019] [Accepted: 05/06/2019] [Indexed: 12/11/2022]
Abstract
BackgroundFlow diverters are a breakthrough treatment for large and giant intracranial aneurysms but carry a risk of periprocedural death or major stroke. Pipeline Flex is a second-generation device that is thought to have lower complication rates because of improvements in the delivery system as well as increased operator experience. Our objective was to analyze the risk of periprocedural death or major complications using Pipeline Flex for unruptured intracranial aneurysms.MethodsA systematic search of three databases was performed for studies of ≥10 treatments using Pipeline Flex for unruptured intracranial aneurysms (2014–2019) using PRISMA guidelines. Random effects meta-analysis was used to pool the rates of periprocedural (<30 days) death, major ischemic stroke, symptomatic intracranial hemorrhage, and minor stroke/transient ischemic attack.ResultsWe included eight studies reporting 901 treatments in 879 patients. Periprocedural mortality (<30 days) was 0.8% (5/901; 95% CI 0.4% to 1.5%; I2=0%). Rate of major complications (death, major ischemic stroke, or symptomatic intracranial hemorrhage) was 1.8% (14/901; 95% CI 1.0% to 2.7%; I2=0%). Aneurysm size ≥10 mm was a statistically significant predictor of a major complication (OR 6.4; 95% CI 2.0 to 20.7; p=0.002). Risk of a major complication in aneurysms <10 mm was 0.9% (95% CI 0.3% to 1.7%; I2=0%). The meta-analysis was limited by the predominance of anterior circulation aneurysms.ConclusionTreatment of unruptured intracranial aneurysms using the Pipeline Flex flow diverter has a low periprocedural risk of death (0.8%) or major complication (1.8%). The risk of a major complication is significantly higher for large/giant aneurysms (4.4%) and is very low for aneurysms <10 mm (0.9%).
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